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. First we will review a wonderful article by Heather Starmer, M.A., CCC-SLP, BCS-S*.


A benefit of FEES is the ability to visualize secretions, which are not seen under fluoroscopy. There are currently two validated and commonly used secretion rating scales for FEES. 

    • Murray Secretion Scale (Murray et al, 1996) is a three point scale which rates the presences of secretions and whether they enter the laryngeal vestibule. 
    • The New Zealand Secretion Scale (NZSS; Miles and Hunting, 2019) is a seven point scale that rates the amount and location of secretions, as well as the clearing response. 

Swallowing Safety

The term “swallowing safety” is used within our field to describe how well an individual can protect their airway from potential invasion of liquids and solids. The most widely used tool for measuring airway invasion is the Penetration-Aspiration Scale (PAS; Rosenbeck et al, 1996). Originally validated using videoflouroscopy, then later validated for use with FEES, this tool measures the depth of and response to airway invasion. There having been rumblings in the dysphagia community about updating this scale (Steel and Grace-Martin, 2017); however, to date there is no validated replacement at this time. 

Swallowing Efficiency

The term swallowing efficiency is used to explain how well material is cleared though the oral cavity, pharynx, and esophagus. There are two scales which have been validated of use with FEES.

    • Boston Residue and Clearance Scale (BRACS; Kaneoka et al, 2013) scores residue based on the amount that cavities are filled using 14 different locations with additional points added for riskier residue locations, multiple residue locations, and whether material is cleared. 
    • Yale Residue Scale (Neubauer et al, 2015) judges presence and amount of residuals in two locations (valleculae and pyriform sinuses)
    • Newer scales have been developed: a more detailed analysis of residual in the valleuclae and pyriform sinuses by Sabrey et al (2021) and a visual analogue scale (1-100) has been explored by Pisegna et al (2018)

There have been efforts in the field to create standardized FEES ratings in a similar way that was pioneer by Dr. Martin-Harris and colleagues with the MBSImP (Martin-Harris et al, 2008). Curtis et al, 2022 created the Visual Analysis of Swallowing Efficiency and Safety (VASES) to standardize definitions for FEES analysis. The Dynamic Imaging Grade of Swallowing Toxicity (DIGEST-FEES; Starmer et al, 2021) scores at the bolus level, but also uses overall patterns to facilitate a severity scope. These scales have been validated for homogenous populations and are not yet validated for general use. 

Main Takeaway

Implementing formal rating scales into FEES documentation helps to increase standardization and comparability. 

Our Takeaway

We understand the swallowing process to be highly variable between people with changes across the lifespan, including fluctuations across and within bolus types (including texture, temperature, and taste). It can be very difficult to standardize a FEES in a clinical (non-research) setting. In our mobile FEES practice, we utilize rating scales and use the mode (most frequently observed score) when analyzing our exams to help with inter- and intra-clinician reliability. We also use the Dysphagia Outcome Severity Scale (DOSS; O’Neil et al, 1999) to determine overall severity. We will keep our eyes peeled for new and updated rating scales and frameworks as our field continues to advance and progress. 

Shameless Plug

Want to practice utilizing rating scales for FEES? We created an in-depth self-study workshop where you can review rating scales and practice scoring FEES exams, comparing your scoring to those of seasoned clinicians! You can check it out here: Get Focused: An Advanced FEES Interpretation Self-Study Course.


*Starmer, H. M. (2022). Incorporating Flexible Endoscopic Evaluation of Swallowing Rating Scales Into Clinical Practice. Perspectives of the ASHA Special Interest Groups, 1-7.