What is FEES?

Flexible Endoscopic Evaluation of Swallowing (FEES)

FEES is Fibreoptic/Flexible Endoscopic Evaluation of Swallowing. It involves the insertion of a flexible, thin tube into the nose. This is called a nasendoscope. It allows visualisation of the throat during swallowing. There is a light and camera attached to the nasendoscope to enable optimal viewing and recording of the assessment. A copy of the videorecording can be provided at no extra cost.

The view from the inside of the throat.

The assessment comprises three parts. The first part involves the assessment of symmetry and movement of swallowing structures (e.g., the walls of the throat, the vocal cords, and the soft palate), without eating or drinking. The second part involves assessment of swallowing using a range of food and fluids which are usually dyed with food dye to enable easier visualisation. The third section involves trying swallowing techniques and positions to overcome any swallowing difficulties. All three sections are required for a comprehensive swallowing assessment.

FEES is not painful, although there is some discomfort when the tube is initially inserted into the nose. However once in place, this discomfort subsides.

Findings from FEES include:

Identification of structural and biomechanical impairments contributing to dysphagia.
Identification of foods, fluids, or saliva “going the wrong way”. This is called aspiration and can lead to aspiration-related pneumonia.
Identification of foods, fluids, or saliva that get stuck in the throat and where it gets stuck.
Identification of foods, fluids, or saliva that are mis-directed into the nose
Identification of strategies, techniques, and positions to improve swallowing (i.e., reduce aspiration and improve clearance of food and fluids from the throat into the oesophagus).
Identification of foods and fluids that are problematic and that should be avoided.

In this video, we see a client who has a feeding tube inserted (NG tube) due to severe swallowing difficulties.

Risks and Benefits

All instrumental procedures carry some risk. FEES has a very low risk of complications.

The most common complication is nose-bleeding (epistaxis). This has been reported to occur in up to 1.2% of assessments. Other complications include vasovagal episodes (fainting) in up to 0.1%, and laryngospasm (involuntary closing of the vocal cords) in up to 0.07%. Reference: Langmore, S.E. History of Fiberoptic Endoscopic Evaluation of Swallowing for Evaluation and Management of Pharyngeal Dysphagia: Changes over the Years. Dysphagia 32, 27–38 (2017). https://doi.org/10.1007/s00455-016-9775-x

The benefits of FEES include:

Correct identification of swallowing impairments, aspiration, and residue. Non-instrumental assessment of swallowing can incorrectly identify dysphagia due to silent aspiration which is when aspiration occurs but there is no cough in response.
Identification of the safest food and fluid consistencies in one assessment, reducing the risk of aspiration or avoiding the need for unnecessary modification of fluids or foods if this has previously been recommended. This can save money by reducing the need for special food or thickened fluids or multiple non-clinical swallowing assessments. Reference: Braun T, Juenemann M, Viard M, et al What is the value of fibre-endoscopic evaluation of swallowing (FEES) in neurological patients? A cross-sectional hospital-based registry study.BMJ Open 2018; 8:e019016. doi: 10.1136/ https://bmjopen.bmj.com/content/8/3/e019016
Improved understanding of the swallowing difficulties by watching the assessment and keeping a copy of the video.
Identification of ways to make swallowing easier and safer to avoid pneumonia and weight loss/malnutrition.