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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
constriction of posterior tongue to
pharynx. Contact between tongue
base and posterior pharynx is
observed. Not all patients will
be able to perform this task, but
if they are able to attempt it, the
information is very useful (Figures
4–6, 4–7, 4–8, and 4–9).
Figure 4–6. Oropharynx expanded (left ) and then compressed (right ) as subject
moves tongue (at arrows
velum.
Figure 4–7. Hypopharynx expanded (left ) and compressed (right ); scope tip is below
the velum.
) posteriorly. Scope is just above oropharynx, at about the
4. ENDOSCOPY IN ASSESSING AND TREATING DYSPHAGIA
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Figure 4–8. Scope tip is just above epi-
glottis; pharynx is expanded.
n
Piriform sinuses, vallecula, pha-
ryngeal walls, base of tongue,
and postcricoid area are examined
for evidence of pooled secretions
(Figure 4–10). At sites of pooling,
the examiner may want to lightly
touch the tissue with the scope
tip and ask the patient to respond
when the stimulus is felt. In the
normal case, there should be no or
minimal secretions at these sites,
perhaps only a few bubbles, and
even light touch with the scope
tip should elicit a response. The
presence of pooling may indicate
poor sensation, or poor ability to
clear tissues. If pooled secretions
clear well with swallow, sensation
may be implicated. Secretions that
do not clear with swallow, on the
other hand, may suggest incomplete or ineffective movements
of structures. In some patients,
sensory and motor functions may
both be impaired.
n
Ask the patient to elevate vocal
pitch to as high a level as possible
while saying “ee.” Observe pha-
Figure 4–9. Scope tip above epiglottis;
pharynx compressed (not a swallow);
upper portion of epiglottis can be seen
between tongue base and posterior pharyngeal wall.
Figure 4–10. Thin secretions in right piri-
form sinus; thick secretions appear as folds
in left piriform sinus and postcricoid area.
ryngeal constriction. Note presence or absence and whether there
is a difference from one side to the
other. Typically, the pharynx does
constrict during this task. The
maneuver is sometimes described
as a surrogate measure of pharyngeal strength, but this has yet to
be documented. However, intact
pharyngeal squeeze has been
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
associated with a reduced risk
of aspiration on pureed foods,
independent of laryngopharyngeal sensation (Perlman et al.,
2004). Fuller et al. (2009) have
also reported a strong association
between the pharyngeal squeeze
maneuver and the pharyngeal
constriction ratio (PCR), which
is a well-documented measure
of pharyngeal constriction determined on fluoroscopy.
n
Ask the patient to hold the nose
and bear down. Observe piriform sinuses for maximal opening. Have the patient relax and
observe return of sinuses to rest.
n
Ask the patient to turn head from
one side to the other. Observe
closure of piriform sinuses (Figure4–11). Note asymmetries from
right to left that may suggest
weakness.
Tasks for Assessment of Laryngeal
Chamber and Valves
Typically, the larynx acts to protect the
airway and assist in opening of the PES
during swallow. The tasks described
here allow the examiner to assess the
Figure 4–11. Piriform sinus on right is com-
pressed with head turned to right.
ability of the larynx to close, thereby
protecting the airway, and to elevate,
further protecting the airway and facilitating opening of the PES. The tasks
also consider the ability of the larynx
to respond to bolus materials that may
come in contact with its structures.
n
With the scope lowered to approx-
imately the epiglottis, ask the
patient to sustain a vowel sound
for several seconds (a high, front
vowel sound, such as “ee,” typically causes the larynx to elevate
and facilitates visualization of
laryngeal structures). If good visualization of the larynx is difficult
because of elevation of the soft
palate, a nasal sound, such as a
sustained “mmm,” may be used
for this task. Observe the mobility
of the true vocal folds, the completeness of closure of the true
vocal folds along their anterior
to posterior dimension, and the
length of time they remain in an
adducted position (patients with
impaired swallow may need to
protect the airway for several
seconds). Note the quality of the
voice produced. Incomplete closure, inability to maintain closure,
and weak, breathy voice quality
may be indicative of vocal fold
dysfunction and compromised
ability to protect the airway.
n
With the scope held in as con-
stant position as possible, ask the
patient to produce a vowel at a
low vocal pitch and to then shift
to as high a pitch as possible. Note
changes in length of vocal folds,
any elevation of laryngeal structures, and the patient’s ability to
raise pitch (Figure 4–12). Typi-
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Figure 4–12. With scope held in place at patient’s nostril, patient is asked to
alternate between low (on left
elongate and appear to elevate on high-pitched production (note slightly
enlarged appearance of true vocal folds and arytenoid structures on L).
cally, raising pitch (fundamental frequency) is associated with
the larynx elevating and, often,
with pharyngeal constriction. An
inability to alter pitch in this way
may indicate some dysfunction of
the superior laryngeal nerve, cricothyroid muscle, or the suprahyoid muscles of the larynx.
n
Observe the patient’s ability
to produce a series of brief /i/
sounds (“ee” as pronounced in
“Pete”), each of which is followed
by inspiration (preferably, through
the nose). Instructing the patient to
sniff after vocalization may facilitate the task. Watch for obvious or
subtle asymmetries in abduction
and adduction of the true vocal
) and high-pitched (on right ) /i/s. True folds
folds that could indicate a paralysis or paresis of one fold.
n
Ask the patient to hold their breath
(Figure 4–13). Observe degree of
adduction of true folds, as well as
any constriction/medialization of
the false folds and/or approximation of the arytenoids to the epiglottis. Typically, the false folds
are closed during breath holding.
With tight breath holding, the larynx may appear sphincteric, with
the false folds constricted and
arytenoids approximating the
epiglottis. This task is a good way
to evaluate all the valves of the
larynx. In Figure 4–14, a patient
has gagged and the larynx has
rocked forward, opening the PES.
Figure 4–13. During tight breath holding, true vocal folds close, then false folds con-
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strict, followed by approximation of arytenoids to epiglottis.
Figure 4–14. During gag, the cricoid can
be seen to rock forward, and the PES opens
(at arrow ).
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This rocking action of the larynx
is also associated with opening
of the PES valve during swallow,
which is not typically observed
during FEES.
n
Observe effectiveness of true fold
adduction for throat clearing and
cough.
Tasks for Assessment of
Swallow Function
Requirements for normal swallow include the transfer of a bolus quickly and
safely from the oral cavity through the
pharynx to the upper esophagus. The
tasks described here allow the examiner
to assess several events before and after
swallow that are critical to this process.
They also illustrate further the value
of endoscopic assessment even when
the patient does not actually swallow
bolus material.
With the scope positioned back in the
oropharynx, bolus materials are introduced, starting with a small amount of
liquid that has been colored green with
food coloring (i.e., edible vegetable
dyes). In our clinic, the standard exam is
begun with a 1- to 3-mL liquid bolus or a
small amount of ice chips. Ice chips may
be particularly helpful in patients who
have not been eating orally for a period
of time (Rees, 2006). With the scope
positioned appropriately for observing
relevant structures, the patient is asked
to perform the following:
n
Hold the bolus in the mouth until
the examiner counts to three, then
swallow. Any early loss of the
bolus into the valleculae or piriform sinuses, or any penetration
or aspiration of bolus material
prior to the swallow, is noted.
n
Following the swallow, sites pre-
viously examined (i.e., nose, valleculae, piriform sinuses, tongue
base, pharyngeal walls, postcricoid area, and true and false vocal
folds) are examined for evidence
of residue. Note the sites and sidedness of residue material and
estimate (if possible) how much
of bolus introduced appears as
residue.
n
If residue is observed, evidence of
repeat swallow is noted. If none is
observed, the patient is asked to
repeat the swallow. Any clearing
that takes place during the repetition is noted.
n
If residue is present on the vocal
folds, cough or throat-clearing
responses are noted. If no response
is noted, the patient is asked to
cough and then repeat the swallow. Effectiveness in clearing residue is assessed.
n
If the swallow approximates nor-
mal, the examiner is unlikely to
observe the instant of swallow
because constriction of tongue and
pharynx obscures visualization.
In patients with weak tonguepharynx constriction, however, it
may be possible to obtain more
information.
Following swallow of the small bolus,
the patient repeats the tasks with a 3- to
5-mL liquid bolus and then a larger selfselected bolus in a cup. For the latter
task, the patient (as able) selects how
much of the bolus material they want
to attempt. These tasks are repeated for
the larger liquid boluses if it appears
safe to do so and with pudding if
difficulties are encountered on any of
the liquid swallows. If the liquid and
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
pudding swallows are managed without incident, the pudding bolus may be
followed by a paste bolus.
These assessment tasks represent
similar tasks, in the same order, as those
used in videofluoroscopic studies at our
institution. If the clinician anticipates
following a patient over time, the ability to repeat at least some of the same
tasks from exam to exam permits more
uniform assessment of progress or deterioration over time. Bolus materials
used for FEES typically do not contain
radiopaque material, although barium
contrast material as used in fluoroscopy
can also enhance visibility during FEES.
In addition, if both fluoroscopy and
endoscopy studies are performed on a
patient, completion of a portion of the
same or very similar tasks on both provides some basis of comparison across
evaluation techniques.
When these protocol swallows are
complete, specific foods that have been
identified as causing particular difficulty for a patient can be tried. Or, if the
objective is to determine if a patient’s
diet needs to be altered, either advanced
or restricted, the exam can be tailored
to answer these questions. In following patients serially, it is important to
maintain a balance between identifying (a) changes in integrity of structures and functions and (b) changes in
swallowing capabilities. Attempting to
adhere to a protocol, that is, some uniformity in tasks and task order across
exams, in our opinion, can usually be
accomplished even with patients whose
tolerance for the exam is quite limited.
Implications of Findings
By the completion of the FEES evaluation, the examiner should have good
insights into the integrity of oropharyngeal and laryngeal structures and
functions for food management and
swallowing. For example, the patient’s
ability to effect linguavelar, velopharyngeal, linguapharyngeal, and laryngeal
valving actions necessary for safe and
effective swallowing should be well
understood. Impressions gained will
lead to therapeutic strategies directed
at improving, bypassing, or compensating for any deficits identified. Similarly,
indications of diminished sensation
identified during the examination will
require consideration of strategies that
may enhance sensory stimulation, as
by manipulating bolus characteristics
or redirecting bolus materials to a more
intact side or site. In like manner, the
patient’s ability to compensate for the
early loss of bolus material, or residue
remaining after an attempted swallow,
will have been sampled across bolus
materials and in terms of both sites and
amounts of loss or residue noted. The
resulting observations will enter into
decisions regarding whether oral feeding is safe or under what conditions it
can be made safer. If a rating scale, such
as the PAS (Rosenbek et al., 1996) or the
Yale Pharyngeal Residue Severity Scale
(Neubauer et al., 2016), is used in the
assessment, the ability to generalize at
least some significant findings from the
study is enhanced.
As noted, a particular appeal of FEES
is the opportunity it provides for assessing the likely benefit of behavioral strategies via therapeutic probes (including
the effects of positional changes, voluntary maneuvers, bolus manipulation,
etc.). The length of the examination is
constrained by the patient’s comfort
and attention levels but not greatly by
concerns about hazards associated with
the examination technique itself. Trial
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probes performed with both examiner
and patient observing the consequences
on the video monitor are particularly
useful. The ability to make observations over time is another feature of
FEES that adds to its value. Evidence
of fatigue in valving functions, consequences of collective swallows, or
residue buildup over precise periods
of time are examples of the kinds of
time-delay observations that can have
implications for treatment planning
and can be explored more thoroughly
with endoscopic evaluation than with
other assessment techniques.
FLEXIBLE ENDOSCOPY AS
A THERAPEUTIC TOOL
Endoscopy is an extremely valuable
assessment tool and an equally useful
tool in the management of dysphagic
patients. Very often in our setting,
patients who have undergone fluoroscopy studies, and for whom particular strategies have been identified as
potentially useful, are brought in for at
least one therapy session to explore in
depth the strategies previously identified. During these “FEESback” sessions,
the emphasis is on assessing the effects
of strategies and on providing clinician,
patient, and other caregivers feedback
regarding these techniques. The conduct of these sessions is different from
an assessment with FEES, particularly
if they occur in close proximity to the
fluoroscopy evaluation and there is no
evidence of significant change in the
patient’s capabilities.
Noted below are therapeutic swallowing strategies, that is, strategies
designed to facilitate safe swallowing.
Visual feedback provided to the patient
during their performance may be use-
ful in teaching their effectiveness and in
improving the patient’s control of volitional gestures involved. (The reader is
directed to Video 4–4, FEESPT1 on the
companion website for an example. The
patient in this clip has undergone base
of tongue/pharynx resection for head
and neck cancer.)
n
Tongue-pharynx constriction: Ask
the patient to produce “ah” or
“uh” and to then move the tongue
posteriorly until pharyngeal frication can be produced.
n
Pharyngeal constriction by pro-
ducing high-pitched vocalization.
n
Laryngeal elevation by raising
pitch, or rapid alternation of high
and low pitches.
n
Breath holding, with true vocal
folds and with sphincteric closure
involving true and false vocal
folds, and arytenoid to epiglottis
approximation.
n
Effects of postural changes, such
as head turning or side lying.
Note changes in voice and breath holding but also any closing off of piriform
sinuses.
Equally important in attempting
strategies that have been identified as
potentially helpful to safe or effective
swallow is the determination of any
aversive consequences of these strategies. For example, the reader is directed
to Video 4–5, FEESPT2 on the companion website. In this clip, a patient
for whom airway protection has been
determined to be impaired is counseled to hold his breath during swallow. Because his transit times have been
determined (via dynamic fluoroscopic
swallow study) to be prolonged, he is
encouraged to hold his breath tightly for
several seconds, thereby protecting his
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
airway throughout the swallow. With
the patient complying with this instruction, that is, “Hold your breath, tighter
. . . tighter . . . ” for a few seconds, a massive reflux event occurs that imperils
his airway. This was not observed on
fluoroscopy and, had we not scheduled
the endoscopic follow-up to assess the
effectiveness and safety of our recommendations, the strategy would have
been recommended to the patient with
no recognition of the potential aversive
consequences it posed to his safe swallowing. We view this type of postevaluation appraisal of any behavioral strategies recommended as a necessary and
valuable part of our management plan
for a patient.
ISSUES AND CONCERNS
Major issues associated with endoscopic examination include the examiner(s), the setting in which the
exam is performed, the use of a topical anesthetic, and other risks posed by
the procedure. The examiner, whether
physician or speech pathologist, should
be skilled in the use of flexible endoscopy and, of course, knowledgeable
about both head and neck anatomy
and the physiology of swallowing. The
setting or settings in which the exam is
performed should have both staff and
equipment resources to respond appropriately to a medical emergency. Some
states, including California, require
that speech-language pathologists
(SLPs) complete a certification program beyond licensure in order to perform endoscopy procedures (details are
specified in California Senate Bills 1379
and 1285). Specific requirements (in
California) include the SLP’s mentor-
ing by an otolaryngologist during the
completion of 25 flexible endoscopic
procedures. The physician must then
document the SLP’s competency to
perform the exam. Beyond this requirement, settings in which the procedure
can be performed must meet certain
requirements regarding the availability
of medical professionals and resources
for the management of a medical emergency. A recent tutorial by Langmore
et al. (2022) discusses FEES training
for clinicians, including training, skills,
and competencies, in detail. (The tutorial represents the most recent position
statement by the American Speech-Language-Hearing Association regarding
the use of FEES and its application by
SLPs since the early 2000s.)
Potential risks associated with the
procedure include vasovagal responses,
nose bleed, and a reaction to the topical anesthetic (if used). Much can be
done to minimize the likelihood of
any of these risks
taking pains to put the patient at ease
before proceeding with the exam, careful insertion of the scope, limitation
of the anesthetic agent to the nasal
mucosa (and away from the larynx),
or performing the exam without an
anesthetic. Precautions for cleaning
and maintaining equipment must be
observed strictly as well. Even with
careful adherence to these guidelines,
however, the potential risks associated
with the procedure require that it be
undertaken, in our opinion, in a setting
with resources available for handling
any emergencies that might arise. In
our setting, all patients who are undergoing bedside, clinical, radiographic, or
endoscopic evaluations for dysphagia
are followed by a team of professionals,
all of whom share in the evaluation of
— for example, by
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83
diagnostic studies and treatment planning for each patient. Similarly, specific
guidelines for use of topical anesthetic
agents, responses to medical emergencies, and cleaning and maintenance of
equipment have been developed by our
institution. Beyond this, our team has
invested considerable time and energy
in continuing education activities, both
formal and didactic, to ensure that specialists who are performing endoscopic
examinations are well qualified to do
so. Depending on individual specialists, patient populations, and settings,
different approaches to endoscopic
swallow studies may be applicable
and appropriate. However, in our opinion, any approach must maximize the
patient’s safety and ensure the most
accurate information possible.
STUDY QUESTIONS
1. What is the difference between
FEES and FEEST?
2. What are the concerns about using
a topical anesthetic agent in assessing dysphagic patients with FEES?
What other risks are associated
with FEES?
3. What aspects of swallowing typically cannot be observed during
FEES that can be observed with
fluoroscopy?
4. Name five indications for using
FEES rather than the modified barium swallow (MBS)/DSS.
5. Name the physiologic “valves”
and “chambers” involved in swallowing. What tasks might you use
to assess the integrity of each with
endoscopy?
6. How might you use endoscopy
to implement information about a
patient’s swallow learned from a
fluoroscopic study?
7. Is there an advantage of using a
standard protocol when assessing
dysphagia with FEES? If so, what?
8. What factors might explain differences in judgments of aspiration
and penetration on FEES and fluoroscopy, respectively?
9. Are there advantages to performing
tasks during FEES that you might
also incorporate in a fluoroscopic
assessment? If so, what?
REFERENCES
Allen, J. E., White, C. J., Leonard, R. J., &
Belafsky, P. C. (2010). Prevalence of penetration and aspiration on videofluoroscopy in normal individuals without
dysphagia. Otolaryngology-Head and Neck
Surgery, 142, 208–213.
Aviv, J. (2000). Prospective, randomized out-
come study of endoscopy versus modified barium swallow in patients with
dysphagia. Laryngoscope, 110, 563–574.
Aviv, J. E., Martin, J. H., Keen, M. S., Debell,
M., & Blitzer, A. (1993). Air pulse quantification of supraglottic and pharyngeal sensation: A new technique. Annals of Otology,
Rhinology, and Laryngology, 102, 777–780.
Bastian, R. W. (1993). The videoendoscopic
swallowing study: An alternative and
partner to the videofluoroscopic swallowing study. Dysphagia, 8, 359–367.
Butler, S. G., Stuart, A., Case, L. D., Rees, C.,
Vitolins, M., & Kritchevsky, S. B. (2009).
Effects of liquid type, delivery method,
and bolus volume on penetration-aspiration scores in healthy older adults during
flexible endoscopic evaluation of swallowing. Annals of Otology, Rhinology, and
Laryngology, 120, 288–295.
Butler, S. G., Stuart, A., Markley, L., & Rees,
C. (2011). Penetration and aspiration in
healthy older adults as assessed during
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