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JCPSLP
Volume 14, Number 1 2012
Journal of Clinical Practice in Speech-Language Pathology
better inform treatment and management of dysphagia.
This may be a relevant consideration in smaller sized health
services without an on-site radiology department. FEES has
the potential to improve patient access to instrumental
assessment.
Neither FEES nor VFSS can be considered to be
an
objective
swallowing assessment, nor to be a
gold
standard
. Both VFSS and FEES rely on the clinician
observing the procedure to make
subjective
judgement
about the visual images obtained. These visual observations
are vulnerable to various influences, human factors,
errors, and biases. Training in the use of instrumental
swallowing assessments improves clinicians’ ability to
use these tools, and can improve the reliability of how
observers identify anatomical landmarks and evaluate the
function of physiological events associated with swallowing
(Logemann, Lazarus, Keeley, Sanchez, & Rademaker,
2000; Wooi, Scott & Perry, 2001; Warnecke et al., 2009b).
There is a growing appreciation and acknowledgement
of the complementary information that VFSS and FEES
provide, and where the findings from both examinations are
integrated, speech pathologists are equipped to provide
a responsive and effective plan for treating and managing
dysphagia (Rugiu, 2007).
Models of service delivery
A FEES procedure can be considered as having three
components:
•
technical – insertion and operation of the endoscope;
•
procedural – direction of the procedure including
providing instruction to the patient and decision-making
regarding textures, volumes, compensatory and
rehabilitative techniques, and manoeuvres to be trialled;
•
interpretive – reviewing images on-line and via the
recordings to evaluate swallowing function, and in turn
use this information to make clinical recommendations
to optimise swallowing safety and efficiency.
Figure 5 shows a speech pathologist performing FEES.
SPs with the appropriate competencies can be responsible
for performing all components of the procedure (SPA,
2003). However, FEES is considered to be an advanced
practice role (SPA, 2003). The competencies required
to conduct FEES are not currently addressed in speech
pathology undergraduate (entry-level) training.
In some instances, FEES may provide better visualisation
of aspiration or penetration. Figure 4 depicts how FEES
is able to identify penetration, where a lateral VFSS image
may not have permitted such vision (the pooling in the
pyriform fossae would obscure the contrast in the laryngeal
vestibule). VFSS, however, is the most suitable examination
when the proportion of a bolus that is aspirated needs to
be quantified (Langmore, 2001).
Figure 3. Lateral radiograph (left) showing residue in the
valleculae. Endoscopic view (right) showing residue in the
valleculae
Milk that has entered the laryngeal vestibule, and
remains above the level of the vocal folds
Residue in pyriform fossae
Figure 4. Endoscopic view showing milk residue in the left
pyriform fossae and the left lateral channel. Milk can also be
seen within the laryngeal vestibule, above the level of the vocal
folds
Practical and logistical differences
There are also distinct practical and logistical differences
between FEES and VFSS. For example, FEES doesn’t
involve exposing the patient to radiation, and therefore, may
be considered the most suitable examination when the
purpose of the examination is to evaluate the effect of
biofeedback on swallowing function (Denk & Kaider, 1997).
Similarly, FEES can be conducted as an extended
examination to enable observations regarding how fatigue
might impact on swallowing function (Warnecke et al.,
2008), repeated examinations for patients with progressive
neurological conditions (Leder, 1998), or a conservative
examination where perhaps swallow trials would be unsafe
for the patient (Langmore, 2001). The portable nature of
FEES also means that patients who may have otherwise
been limited to clinical swallowing assessment as a result of
the acute nature or fragility of their primary medical
condition, or physical status including issues with
positioning, are able to undergo instrumental assessment to
Figure 5. Michelle Cimoli, speech pathologist, performing FEES
in an outpatient clinic at Austin Health
A reasonable body of published research now
demonstrates the safety of FEES when it is conducted by
trained SPs (Aviv et al., 2000; Aviv, Murry, Zschommler,