Report Writing for FEES Examinations
INTRODUCTION
Source of referral – why referred
Relevant medical history:
Contributing med diagnoses
History of swallowing problem (onset, course)
Patient complaints today
Speech/voice/cognitive status (if appropriate)
A FEES PROCEDURE WAS DONE TO EVALUATE SWALLOW FUNCTION post
tracheostomy capping to rule out aspiration.
Part I Findings:
On entry to the laryngeal vestibule, pt noted with edema of the arytnoids (increased in Lt.
arytnoids) resulting in asymmetry of the lateral channels. Prior the swallow pt noted with
Mild Secretions in the pyriform and lateral channels that was pooling outside laryngeal
vestibule corresponding with level 1 of secretions on the Murray Scale (1996).
Phonation: upon phonation of /ba-ba-ba/ and /m/ pt noted with intact elevation and lateral
wall movement of the soft palate with adequate VP closure. However, pt noted with reduced
laryngeal mobility, amplitude, precision, and speed of vocal fold and arytnoids movement
upon phonation. Upon glide up pitch, pt noted with reduced arytnoids lift and VF lengthen.
Pharyngeal squeeze: reduced constrictor muscles, lateral wall medialization
Airway closure: present, as indicated by whiteout during the swallow
Laryngeal elevation: present, slightly reduced indicated by residues in the vallecula and the
pyriforms. Epiglottal retroflexion present, but reduced as seen by residues and mild sluggish
movements.
BOT retraction
Part II
The patient was presented with ice chips, thing, nectar, puree, and soft solids (bread) dyed green
for visualization.
The swallow was characterized by:
Initiation
Timely swallow initiation with absent penetration/aspiration prior the swallow.
Airway protection during the swallow
Complete
Bolus clearance
Reduced post swallow pharyngeal clearance, with multiple swallows post initial swallow
to clear
X1 evidence of penetration from residues with that cleared with spontaneous multiple
swallows and cued throat clearing.
IMPRESSIONS:
FEES revealed Mild pharyngeal dysphagia secondary to endotracheal intubation/trach
characterized by mild residues post the swallow with consistencies that clears with spontaneous
multiple swallows and cued throat clearing with absent aspiration/penetration with all presented
consistencies.
Consistent with medical diagnosis?
RECOMMENDATIONS
1. Initiate oral feeding of all consistencies as tolerated
2. Dietitian and physician were contacted regarding plan.