FEES

Question 1

Fiberoptic Endoscopic Evaluation of Swallowing

Answer 1

• FEES
  1. Used to examine the pharyngeal swallow initially in l988
  2. Used as an alternative when MBS was not available
  3. Widely used today
  4. A FEES is not a screening tool.
  5. A FEES is a 3-D evaluation by SLP’s of:
  a. Anatomy & physiology of the pharynx & larynx
  b. Swallow function
  c. Postural, dietary and behavioral strategies.
  6. FEES is not a duplicate of fluoroscopy but can reveal some unique findings and may be the preferred examination for a patient with dysphagia.

Question 2

2 Components of FEES training

Answer 2

1. Knowledge based
2. Hands on practice- 10 normal subjects and 15 abnormal subjects

Our code of ethics: “engage only in those practices that are within our scope of competence.” (If we are not competent we shouldn’t be doing it)

Question 3

MD vs SLP

Answer 3

1. MD: most interested in diagnosing the underlying medical problem causing dysphagia
2. SLP is interested primarily in identifying a dysphagia, understanding the nature of the dysphagia and planning treatment.

Question 4

Time of Endoscopy

Answer 4

1. Endoscopy is not time restrained as fluoroscopy is.

2. We can stay in the nose while the patient eats their entire meal- can watch for fatigue

Question 5

Pros of Endoscopy (5)

Answer 5

Repeat endoscopy exams can be done more easily and with less hesitation than fluoroscopy because they:

1. Cost less
2. Deliver no radiation
3. Can be brought to the patient
4. Can be used as biofeedback
5. Can observe patient in their natural feeding environment

*** Can perform more than 1 time in a day if you need to.

Question 6

Five components of FEES

Answer 6

1. Assessment of anatomy of the pharyngeal stage as it affects swallowing (can only see this stage)
2. Assessment of movement and sensation of critical structures within the hypopharynx and laryngopharynx
3. Assessment of secretion management (MBS cannot do this)
4. Direct assessment of swallowing function for food and liquid
5. Response to therapeutic maneuvers, interventions and behavioral strategies to improve safety & efficiency of the swallow.

Question 7

Indications for a FEES exam (9)

Answer 7

1. Positioning in fluoroscopy problematic
2. Transportation to fluoroscopy problematic
3. Concern about excess radiation exposure
4. Severe dysphagia with very weak or possibly absent swallow response
5. Post-intubation or post-surgery. Endoscopy can visualize larynx directly for signs of trauma or neuro damage
6. Tracheostomy if you suspect laryngeal competence may be compromised (don’t have a passy muir speaking valve)
7. Need to assess fatigue or swallow status over a meal
8. Repeat exam to assess change; to assess effectiveness or need for maneuvers
9. Biofeedback- can reassess a chin tuck with FEES

Question 8

Do FEES when patient demonstrates: (5)

Answer 8

1. Hypernasal voice
2. Hoarse, breathy voice, or aphonic
3. Wet voice quality
4. Rapid respiratory rate; effortful breathing (can they hold their breath well enough to swallow)
5. Inability to handle saliva/secretions
   a. Good for these because you will get to see the larynx and VF.

Question 9

FEES limitation

Answer 9

1. Can not see aspiration during the swallow – can only infer.
   a. Can see before and after

Question 10

Indications for Fluoroscopy (7)

Answer 10

1. Patient will not accept/tolerate endoscopy
2. Suspected oral stage problem that should be imaged
3. Esophageal stage problem or GER suspected
4. Globus complaints, possible CP dysfunction
5. Vague symptomotology from patient
6. Need to verify aspiration of thin liquids during the swallow
7. Need to get better impression of amount of aspiration.

Question 11

Risks of Endoscopy/Contraindications (9)

Answer 11

1. Agitated; tactily defensive patient
2. Hyperactive gag reflex- should be off velum and back of the tongue
3. Small nasal passage (nasal stenosis)
4. Pharyngeal stenosis
5. Not sufficiently alert to be fed orally
   Patient has movement disorder (chorea)

• Need two people- someone to feed and someone to do the scope
  6. H/o epistaxis (nose bleeds)
  7. Bleeding disorder
  8. History of fainting
  9. Acute cardiac problems which predispose to bradycardia

** = have medical help present or don’t do FEES

Question 12

Adverse Reactions- (7)

Answer 12

1. Discomfort – most common
2. Gagging/vomiting
3. Nose bleed/perforation
4. Laryngospasm- need to touch the larynx and VF
5. Vasovagal response- fainting
6. Tachycardia
7. Nasal inflammation

Study of 6000 exams – 73 examiners
a. 20/6000 (.3%) epistaxis- bloody nose

b. 2/6000 (.03) fainted
c. 2/6000 (.03) laryngospasm

Question 13

Universal precautions (3)

Answer 13

1. Gloves
2. Eye protection – optional
3. Endoscope high-level disinfection

Question 14

Endoscopic equipment (6)

Answer 14

1. Flexible endoscope
2. Light source
3. Camera and adapter
4. Video recorder and monitor
5. Optional: air pulse generator for sensory testing (FEESST)- burst of air into the throat to observe sensation
6. Miscellaneous supplies

Question 15

Positioning

Answer 15

1. Position the patient in a posture that is typical of how he or she eats
2. Position the patient in a posture that would be preferred over the current posture and is realistic for the setting.

Question 16

FEES Procedure (7)

Answer 16

1. Clean and stimulate the mouth prior to starting exam- ice chips
2. Explain the procedure
3. Anesthesia?- typically stopped using anesthesia
   a. Lidocaine gel on cotton tipped applicator
   b. Lidocaine soaked cotton gauze
   c. Decongestant- can use nasal spray to lessen decongestant
4. Prepare the food
5. A fiberoptic laryngoscope is passed transnasally to the hypopharynx to view the larynx and surrounding structures- getting it in is the skill
6. Patient is led through various tasks to evaluate the sensory and motor status of the pharyngeal and laryngeal mechanism
7. Food and liquid is provided to assess the integrity of the pharyngeal swallow.

Question 17

What to look for during FEES (11)

Answer 17

1. Ability to protect the airway- are they closing the VF
2. The ability to sustain airway protection for a period of several seconds- can they do this for 5-7 secs.
3. Ability to initiate a prompt swallow without spillage of material into the hypopharynx
4. Sensitivity of the pharyngeal/laryngeal structures
5. The effect of anatomy on the swallow
6. Appropriate postural changes and swallowing maneuvers are attempted as soon as problems are detected so that the examiner can determine the optimal interventions to improve the safety and efficiency of the swallow.
7. Timing and direction of movement of the bolus through the hypopharynx
8. Ability to clear the bolus during the swallow
9. Presence of pooling and residue of material in the hypopharynx
10. Timing of bolus flow and airway protection
11. Patient response to residue, penetration and aspiration

Question 18

Use of food dye- 7

Answer 18

1. Originally, it was common practice to tint food blue or green for better visualization.
2. Food dye was commonly used in enteral feeds to detect aspiration.
3. 2003 – FDA warned us of serious adverse events associated with the use of blue dye.
   a. Medical world should not use it, 12 deaths
4. Instead of excreting the dye, patients with increased gut permeability were found to absorb the blue dye
5. This discolored body fluids and skin and caused at least 12 deaths.
6. Patients at risk for increased intestinal permeability include those with:
   a. sepsis
   b. surgical interventions
   c. burns
   d. renal failure
   e. trauma
   f. shock
   g. inflammatory bowel disease
7. Instead of blue or green dye, use foods with natural color.- grape juice, milk, orange juice

Question 19

Protocol (5)

Answer 19

1. Assessment of anatomy and sensorimotor function of the:
   a. Velopharyngeal mechanism

b. base of the tongue and pharyngeal
structures(at rest and in motion)

c. laryngeal structures (at rest & in motion)
2. For all movements, note:
a. Symmetry
b. Range of movement
c. Agility/Briskness of movement
d. Precision/timing/coordination
3. Delivery of food and liquid
4. When abnormal swallowing behaviors are identified – the examiner generates hypotheses about their cause and then tests the hypotheses by asking the patient to perform tasks
a. Premature spillage, chin tuck, ask them to hold (anterior bolus hold), try teaching a supraglottic swallow to close the larynx or the mendelsohn to clear the pyriform swallow
5. Make appropriate therapeutic recommendations.

Question 20

1. Importance of Secretions
2. Describe secretions
3. Murray’s Findings

Answer 20

1. Secretions are predictive of swallowing success.
2. Rating of secretions:

0 Normal (moist)

1 Pooling outside of laryngeal vestibule anytime during observation

2 Pooling in laryngeal vestibule transiently, spills in over the observation period or patient clears them at some point

3 Pooling in laryngeal vestibule consistently. There continuously and patient does not clear them.

2. Describe secretions:
   a. Appearance (color, viscosity) Thick, stringy, creamy, clear and frothy (not as bad), blood tinged
   b. Patient response (sensitivity)
   c. Do they clear with spontaneous or cued swallows
   d. Frequency of spontaneous swallows

3.
a. 100% of pts. rating a 2 or a 3 aspirated food or liquid

b. 53% of pts. rating a 1 aspirated food or liquid

c. Ratings of 2 or 3 high risk for aspiration
Rating of 1 considered at risk

See secretions- usually indicates that they won’t be very successful at eating safely

Question 21

Ice Chip Protocol

Answer 21

If patient demonstrates a great deal of secretions and they cannot be cleared either spontaneously or through cued swallows, consider an ice chip protocol.

1. If ice chips were never even partially swallowed, recommend aggressive management of secretions & oral hygiene
2. If ice chips are beneficial(stimulated more frequent swallows, cleared or thinned the secretions), recommend delivery of ice chips in regulated amounts, several times/day.

Question 22

If the bolus spills into the pharynx, what path does it take? (4)

Answer 22

1. Outside the larynx
2. On the rim of the larynx
3. Within larynx
4. Penetration/aspiration – use a modified Rosenbek scale

Question 23

5 pt. Ashford Scale

Answer 23

1. normal
2. laryngeal penetration- cough it out
3. Penetration without clearing
4. Aspiration with clearing
5. Aspiration without clearing

Question 24

How adequate are structural movements during swallow?

Answer 24

1. Bolus driving, clearing forces and laryngeal elevation

2. Valving forces

Question 25

1. If residue, is it | 2. Other observations:

Answer 25

1. Outside larynx a. Base of tongue b. Pyriforms c. Posterior pharyngeal wall d. Diffuse 2. On rim of larynx 3. In larynx 2. a. Backflow from the esophagus b. Patient response to presence of endoscope

Question 26

Therapeutic maneuvers and their effect (4)

Answer 26

1. Alterations in bolus and mode of delivery 2. Effective postural changes 3. Effective maneuvers/strategies 4. Effectiveness of biofeedback

Question 27

In general, interpretation follows a consistent format: (5)

Answer 27

1. Anatomical/structural deviations 2. Movement deviations 3. Sensory deficits- is pt aware of residue? 4. Specifics of swallowing function/dysfunction 5. Interpretative assessment of swallowing safety

Question 28

Clinical findings better revealed endoscopically (18)

Answer 28

1. Anatomical relations; alterations in anatomy, edema 2. Effect of feeding tube or recent endotracheal tube on anatomy and swallowing 3. Velopharyngeal closure; nasal reflux 4. Frequency of spontaneous or dry swallows. 5. Status of secretions; ability to sense & clear 6. Respiratory rate, rhythm and effect on swallowing 7. Ability to achieve and maintain airway closure to protect airway 8. Pharyngeal/laryngeal sensation 9. Status of airway protection 10. Location of spillage; penetration of spillage 11. Residue build-up and patient response 12. Aspiration of residue after the swallow 13. Fatigue over a meal 14. Effectiveness of postural change to alter path of bolus flow- can see if it is symmetrical 15. Ability to hold breath volitionally or sustain breath holding 16. Effect of different bolus consistencies, temperatures, taste 17. Esophageal to pharynx reflux 18. Laryngeal signs of GERD

Question 29

Clinical findings better revealed fluoroscopically (14)

Answer 29

1. Tongue containment, mastication of the bolus 2. Tongue propulsion at onset of swallow 3. Coordination of oral and pharyngeal movements 4. Arytenoid contact to epiglottis during the swallow (whited out on FEES) 5. Completeness of epiglottic retroflexion during the swallow Gold standard- you can see all phases of swallow - You can see tongue pumping on FEES, but you see more of the coordination with MBS 6. Hyolaryngeal excursion 7. Laryngeal elevation 8. CP opening; timing of opening 9. Airway closure at level of arytenoid to epiglottal contact 10. Aspiration during the height of the swallow 11. Esophageal clearance 12. Gastroesophageal Reflux 13. Ability to produce effortful swallow and 14. Mendelsohn maneuver (better seen because you can see hyoid bone on MBS)

Question 30

Sensitivity 1. FEES 2. MBS

Answer 30

1. FEES a. pharyngeal stasis (residue) b. penetration c. aspiration d. effective cough reflex 2. MBS a. premature oral leakage