FEES and MBSS

When you have the choice of endoscopy and flouroscopy to evaluate swallowing, why choose FEES?

Your patient has positioning limitations, or does not tolerate leaving the facility or room.

FEES is conducted at the patient's bedside or while they sit in a chair in their own room.  If the patient cannot sit upright, FEES is completed in the position that the patient will be in during eating. There are no limitations. 

Because the patient does not require transport and is in a comfortable position for testing, they a kept comfortable and testing duration is not affected.  Additionally, a real view of swallowing in the patient's actual eating position is assessed.

Example Patients: bariatrics, bed bound,  cerebal palsy, ventilator dependent, easily fatigued,  painful wounds. 

Your patient has severe pharyngeal dysphagia, and aspiration during testing is a concern.

Aspiration of secretions is the biggest predictor for aspiration pneumonia.  Patients who aspirate their secretions are the most at risk.

FEES is a sensitive, conservative instrumental assessment of swallowing.  Aspiration of secretions can be evaluated, as can ice chips, as there is a direct view of the laryngeal vestibule, without use of barium and radiation. 

There is no need to delay testing for patients who have severe-profound dysphagia.  Critical information can be obtained regarding the patient's specific physiologic swallowing impairments and anatomical integrity, to allow for appropriate therapy plans to be established right away. No guessing!

Example patients:  PEG dependent,  NPO, silent aspiration risk/impaired cough relfex. 

Your patient may have respiration and swallowing incoordination.

The prevelance of dysphagia in COPD and other pulmonary disorders is high.  Research shows that patient's with COPD have a high propensity for aspiration, and have reduced laryngeal sensation to aspiration.  In addition, the pulmonary patient frequently coughs outside of oral intake, making it  difficult to determine if dysphagia is present.

FEES offers a view of the swallow and respiratory pattern with a direct view of the airway and pharyngeal swallow.  Disruptions in coordination as well as the impact of shortness of breath across trials can be assessed during FEES.

Example Patients: COPD,  tracheostomy, ventilator dependent, anyone with reduced respiratory capacity/fatigue

Your patient will benefit from assessment with real foods and liquids.

The sensory properties of a bolus are well known to impact swallow physiology.   The taste, texture, and temperature of barium may be rejected by some patients, and limit the flouroscopic evalulation.

In addition, some patients cannot tolerate barium without G.I. upset, or are allergic to contrast. 

Any of these challenges are considerations for obtaining an accurate instrumental evaluation of swallowing.  Real foods and liquids are utilized during FEES.  FEES can even be conducted with specific food items that have been problematic for a patient, to determine the deficit with a particuliar bolus when needed. 

Example Patients:  dementia, cognitively impaired, right CVA. 

Your patient may have reflux or other G.I. issues.

You note frequent throat clearing, your patient reports globus, or perhaps you've observed aerophagia and signs of regurgitation of a bolus.

Through FEES, the evidence of reflux in the pharynx and larynx can be graded using the reflulx finding scale.  Tissues are viewed directly, and findings of edema, erythema, endolaryngeal mucus, and other anatomical changes are assesed as a component of FEES testing.

Regurgitation of material can also be viewed, as it returns from the upper esohageal sphincter into the pharynx.

When findings consistent with esophageal dysphagia or reflux are present, appropriate recommendations for endoscopy with Gastroenterology or management of abnormal laryngeal findings are referred to ENT.   FEES points the clinician in the right direction for the patient's clinical management.

It is a misconception that the MBSS evaluates the esophageal stage of swallowing.  A full esophagram and/or esophagogastroduodenoscopy (EGD) are the appropriate medical tests for follow-up when esophageal dysphagia is present. 

 

You value assessment of anatomical integrity for your patients.

Clinicians who have access to FEES for evaluation of swallowing  have the advantage of viewing the patient's vocal cord function and the presence of obstructing anatomy for functional swallowing (such as edema or lesions). 

FEES also yields assesment of secretion management, the quality of the patient's oral care and suction routine,  and can determine if there is possible anatomical pathology that warrants further medical management to progress the patient's care. 

Example patients:  dysphonia, vocal fold paralysis, intubation history, radiation history, surgical history in throat, tracheostomy, presence of a nasogastric feeding tube, GERD, LPR, concern of secretion aspiration, & complaints of globus.
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