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Professional issues
18
JCPSLP
Volume 14, Number 1 2012
Journal of Clinical Practice in Speech-Language Pathology
Michelle Cimoli
(top) and Joanne
Sweeney
This article
has been
peer-
reviewed
Keywords
fibreoptic
endoscopic
evaluation of
swallowing
(FEES)
service delivery
models
training
swallowing (FEES) are the most widely employed
instrumental swallowing assessments used to evaluate
oro-pharyngeal swallowing function. As instrumental
swallowing assessments, both FEES and VFSS aim to
achieve the same broad objectives. They can be used to
discriminate between normal versus abnormal swallowing
and where dysphagia is identified, to determine the level of
function and impairment ([CASLPO], 2007 and [ASHA],
2000). Both FEES and VFSS enable judgements to be
made about which textures, consistencies, volumes, rate,
and methods of delivery maximise safety and efficiency of
the swallow. Both examinations can also be used to
evaluate the effectiveness of compensatory or rehabilitative
interventions (Carnaby-Mann & Lenius, 2008; Leder &
Murray, 2008).
VFSS and FEES
VFSS is the most widely used instrumental swallowing
assessment. VFSS provides radiographic images of the
upper aerodigestive tract, enabling observations to be
made of the oral, pharyngeal, and upper oesophageal
phases of swallowing, as well as the interplay between
these various stages of swallowing (Martin-Harris & Jones,
2008). This view is generally regarded as providing the
superior view of oral stage function (Langmore, 2001). It is
also often the more appropriate examination when
symptoms are vague, and an overview of swallowing
function across the various phases is indicated (Langmore,
2001).
The value of the visual images provided by VFSS
depends on the clinical question that needs to be answered
for a particular patient’s clinical management. There are also
practical and logistical considerations that may limit access
to VFSS for some patients.
FEES is not only an alternative instrumental assessment
to VFSS. It is an examination that can provide unique
information about swallowing function that, for some
patients, may be more clinically relevant. FEES
involves passing the flexible portion of an endoscope
(nasendoscope/rhinolaryngoscope) through the nose while
connected to a camera to enable audio-visual images to be
captured. In the oro-pharynx, where the scope is positioned
for the most part of the examination, ideally, the base of
tongue and laryngeal vestibule are in full view. The scope
can be advanced inferiorly to enable the sub-glottic region
to be visualised.
Research has shown FEES to be a viable tool for
identifying and characterising features of swallowing
Fibreoptic Endoscopic Evaluation of
Swallowing (FEES) is an instrumental
swallowing assessment increasingly used
by speech pathologists (SPs) in Australia.
The Speech Pathology Australia (SPA)
position paper published in 2007 reflected
the growing use of the technique by SPs in
Australia at the time. Evidence supporting
the use of FEES for diagnostic and treatment
purposes has continued to strengthen, and
now demonstrates that FEES can provide
important clinical information to guide
management of dysphagia. Many models of
FEES service delivery remain strongly
influenced by historical attitudes to the use
of endoscopy. Some of these models are
expensive and impose a significant cost on
health care providers in terms of paid time,
as well as having an impact on how patients
can access the procedure. This paper
provides a brief overview of the relevant
literature regarding FEES, including a
discussion of some of the points of difference
between videofluoroscopic swallowing
studies (VFSS) and FEES. The paper also
discusses service delivery models and
approaches to training. A well-considered
approach to training is an integral part of
developing a sustainable FEES service to
ensure safe, effective, and equitable access
to patients.
Instrumental swallowing
assessments
Speech pathologists use both clinical (non-instrumental)
and instrumental techniques to assess swallowing function
(American Speech-Language Hearing Association [ASHA],
2000; Carnaby-Mann & Lenius, 2008); College of
Audiologists Speech-Language Pathologists of Ontario
[CASLPO], 2007. In many instances, an individual patient’s
swallowing function is assessed using both clinical and
instrumental assessments. Videofluoroscopic swallowing
studies (VFSS) and fibreoptic endoscopic evaluation of
Fibreoptic Endoscopic
Evaluation of
Swallowing (FEES)
Models of service delivery and approaches to training
Michelle Cimoli and Joanne Sweeney