The most recent Perspectives publication for ASHA’s Special Interest Group 13 included several articles on the topic of FEES. Over the next few weeks we will summarize some of the articles for you. Today’s blog will focus on a new article by Dr. James Curtis, PhD, CCC-SLP.

Curtis, J. A. (2022). A Scoping Review and Tutorial for Developing Standardized and Transparent Protocols for Flexible Endoscopic Evaluation of Swallowing. Perspectives of the ASHA Special Interest Groups, 1-12.

The article starts at the beginning of FEES-time, back in 1988 when Dr. Langmore first introduced FEES to our field. A review of FEES strengths and limitations is included and much of this research includes comparison to videofluoroscopic swallowing exams. Because there is limited reliability for addressing swallowing kinematics using FEES based on Dr. Logemann’s research and the fact that information on swallowing kinematics is surmised by looking at bolus flow and patterns of residue, Dr. Curtis makes a point to avoid commenting on physiology when utilizing FEES, as it is not directly visualized. 

Dr. Curtis describes the advantage of FEES as the visualization of functional swallowing outcomes, as it has been demonstrated in research to be superior when compared to  videofluoroscopy in identifying pharyngeal residue as well as laryngeal penetration and aspiration, as these events are correlated with negative sequelae. 

Examination Preparation Parameters: Because a small amount of discomfort is experienced during FEES, there is research that further examines methods to minimize discomfort.

  • Topical Nasal Anesthesia – most of the research included in the review found no change in the physical experience with vs. without topical anesthesia. Also, there is some documented risk of altering swallow function by numbing the pharynx. 
  • Decongestants/Vasoconstrictors – most of the research found no change to the physical sensation of the endoscope with use of vasoconstrictor. 
  • Lubrication – lubricating jelly does not seem to change the patient’s sensation of the endoscope; however, it does seem to make it easier to move the scope through the nasal passage, yet may compromise endoscopic view. Water and saline spray also did not appear to change patients’ comfort ratings. 
  • Anxiety – a few studies have found that when patients have a higher level of anxiety, they tend to experience more discomfort during the exam. 

Swallowing Instructions: Verbal Cueing and Bolus Holding:  Several research articles have demonstrated that bolus holding alters swallowing physiology, thus Dr. Curtis suggests deciding when to use these cues in order to get a picture of uncued and cued swallowing. 

Bolus Volumes: Sip size is the portion of liquid taken into the mouth when consuming a beverage. Bolus volume refers to the amount that is propelled into the the pharynx during a swallow. When bolus volume is less than the sip size, this is often referred to as piecemeal. Dr. Curtis includes recommendations for measuring self-selected volumes as well as pre-measured volumes in order to be as precise as possible. Some protocols use 5 ml bolus size; however, this is much smaller than is typical for most adults (typical sip size approximately 20 ml). If swallowed in multiple swallows, it would be impossible to measure how much bolus volume was swallowed each time, thus a verbal cue to drink it all in a single swallow may be warranted. 

Bolus Consistency: Testing a range of consistencies is common. Some research indicates that using specific textures will reveal different swallowing components, thus not all boluses (such as mixed textures) need to be tested. Dr. Curtis recommends 5, 10, and 20 ml, as well as self-selected volumes with thin, pudding, and solid crackers. 

Number of Trials: Only one study has examined this and found that there was increased identification of aspiration by the 9th trial. Dr. Curtis suggests using at least 5-6 trials of each bolus volume and consistency; however, he did indicated more research is needed in this area. 

Colerants and Camera Positioning: Color, opacity, and coating effect has been examined in regard to FEES, and the current consensus is that blue seems to show up a bit better than green and white when it comes to identifying penetration, aspiration, and residue. More opaque materials are better than translucent materials. That being said, more opaque colors (white) often leads to a coating effect, which may “gunk” the tip of the endoscope. To remedy this, Dr. Curtis suggests using a higher scope position to stay out of the path of the bolus, as well as alternating with blue/translucent to “clean the slate” between white trials.

Takeaway: Dr. Curtis surmised that it is ideal to utilize a standardized and transparent FEES protocol in the clinical setting. He provided three figures to demonstrate an overview of what to consider when developing a protocol, a sample written protocol, and an image of a FEES set-up.

Our Takeaways:

  • In our mobile FEES practice, we do not use topical nasal anesthesia or decongestants/vasoconstrictions. It is up to the clinician’s discretion whether to use lubricating jelly. We have mastered the art of building a quick rapport with our patients and use techniques to ensure they are as calm and comfortable as possible before initiating the exam, which seems to be the most important part. 
  • We do not cue the patient to hold a bolus unless we are utilizing a bolus hold maneuver as a compensation or to help us determine if there is an oral containment issue. Whenever we recommend any type of compensation, we give the exact verbiage in order to ensure that those who work with the patient will elicit the exact same response by providing the same cues. 
  • Protocols are individualized to each patient. CSP provides an array of bolus textures and volumes, as well as multiple trials of each, as appropriate. We also ask if there is anything specific that the patient has been asking for, or has reported increased difficulty with. Use of blue food coloring, alternating with green, is utilized, as well as white as an adjunct if needed. It is important to note that the structural coating from opaque white coloring may lead to greater severity ratings on the PAS and residue scales, therefore alternating colors helps ascertain “real” residuals from coating.