The Use of Fibreoptic Endoscopic
Evaluation of Swallowing (FEES)
with Complex Dysphagia
Vanessa Richards &
Zoë Sherlock
Clinical Lead Speech &
Language Therapists
Considerations…
 Over 123,000 patients
admitted with a
primary or secondary
diagnosis of
dysphagia in
20013/14
 Mean LOS = 7 days
 Dysphagia and
aspiration highly
associated with
pneumonia and death
Clinical Examination
 Assessment involves:
 Full case history
 Oro-motor examination
 Oral trials as appropriate with strategies,
texture modification
 Unreliable in detecting aspiration
Tools to Bedside Assessment
 Cervical auscultation
(Stroud et al 2002,
Leslie et al 2003)
 Pulse oximetry
(Wang et al 2005,
Higo et al 2004)
 Both unreliable in
detecting aspiration
Videofluoroscopy
 Dynamic fluoroscopic imaging procedure
 Assessment of oral, pharyngeal and oesophageal
stages
 Views in lateral and antero-posterior planes
 Uses barium
 Exposure to radiation
 Conducted in radiology dept.
 Medically unwell or immobile patients unsuitable
VF- Aspiration
Limitations of VF
 Not suitable for some patient groups e.g.
critically unwell, high O2 requirements,
tracheostomy, bed-bound, severe kyphosis,
claustrophobia, severe agitation/confusion
 Cost and staffing
 Radiation exposure
 Difficulty with access
 Uses barium
Fibreoptic Endoscopic Evaluation
of Swallowing (FEES)
 Flexible nasendoscopy used
 Assessment of pharyngeal and laryngeal anatomy
and physiology
 Assessment of secretions
 Uses real food
 Minimal risks and contraindications
 Repeatable
 Can be done at bedside
Advantages of FEES
 Very high risk of aspiration
 Evaluation of secretion management
 Visualisation of altered laryngopharyngeal
anatomy/physiology
 Suspected impairment of sensation
 Extended assessment possible
 Uses real food/fluid
 Biofeedback
 Repeatable
 Can be done on unit
FEES
Case Study
 71 year old lady admitted with peritonitis due
to C. diff. Transfer to GICU post total
colectomy & ileostomy
 PMHx:
 L thyroid lobectomy (diffuse large B cell
lymphoma)
 L TVF palsy. Dysphagia and dysphonia
 Post op. pharyngo-cutaneous fistula requiring
NBM and PEG
Case History Cont.
 FEES 1 - ++ upper airway secretions. No
pooled secretions in pharynx/larynx. L TVF
palsy. Poor compensation from R. Silent
aspiration
 Return to theatre & surgical tracheostomy
 Pseudomonas in sputum
 No air leak around trache with cuff ↓ on
bedside ax
Case History Cont.
 FEES 2 ↑ airway closure but weak SP and
BOT with pre-swallow loss on all oral trials
with silent aspiration. Remain NBM with
dysphagia exercises
 Tolerating SV. Good voice
 FEES 3 Much improved. No overt aspiration
with thin and soft but silent aspiration on
puree. Started on ‘tasters’ due to fatigue
Case History Cont
 Failed mini-trache trial due to copious
secretions
 FEES 4 Not suitable for VF due to
secretions and infection. Occasional preswallow loss. Residue build-up with thicker
consistencies. Poor sensation on-going. Left
on ‘tasters’ chilled water only
 Decannulated
Case History Cont.
 FEES 5 Reduced sensation but improved
movement and cough. Diet ‘tasters’
introduced using strategies
 Diet increased to half portions
 FEES 6 Laryngeal penetration with
increased amounts fluid. Improved with chin
tuck and double swallow. Soft/normal diet
 Discharged after monitoring at bedside
 In hospital for 4 months
In Summary…
 FEES essential because:







silent aspiration
bed-bound, O2 and suction reliant
infection status
bio-feedback for pt. and husband
implementation of strategies and therapy
repeatable
risk management in view of acuity and complexity of
presentation
 informed MDT management
To Conclude…
 FEES is an essential part of dysphagia management for in
and out-patients with complex dysphagia
 “Just wanted to say a quick thank you for your help today.
You really helped me understand what is happening
functionally in my throat, & more importantly, what I can do
to alleviate the situation. I can’t begin to convey what a
relief it is to know that things can be under ‘my’ control
again after your excellent explanations & guidance. Really
appreciated being shown the images too seeing what is
actually happening with explanations that this layman can
understand”