FIBREOPTIC/FLEXIBLE ENDOSCOPIC

EVALUATION OF SWALLOWING (FEES)

Dr Mukundan Subramanian
ORAL LIP CLOSURE
Food held in mouth anteriorly

PREPARATORY
TENSION IN LABIAL AND BUCCAL
MUSCULATURE
To close anterior and lateral sulci

ROTARY MOTION OF JAW

For Chewing

LATERAL ROLLING MOTION OF

TONGUE
To position food on teeth during
Chewing

SOFT PALATE DEPRESSED

TOWARDS BOT
To seal the oral cavity posteriorly and
widen the nasal airway
 ORAL
TRANSPORT
PHASE
PHARYNGEAL PHASE
Pharyngeal trigger

Not a true reflex

Patterned motor
response based upon
type of liquid or
food to be swallowed

Food properties:
Texture/ Taste/
Volume
1. Nasopharynx Closure
To prevent backflow of material up the nose

2. Base of Tongue Retraction

Propels Bolus throught the pharynx

3. Pharyngeal Contraction
To clear residue through the pharynx

4. Airway protection
Laryngeal Elevation and Closure

5. Cricopharyngeal Sphincter opens

 Neurologic deficiencies
result in a

Shortening in opening
phase of UES, despite
normal relaxation of CP
muscle itself

This increases the possibility of

postcricoid residue which may
be at risk of aspiration after the
swallow is completed
Esophageal Phase
 Dysphagia- Common/ Costly

Adults > 50, prevalence ranges from 7% to 22%

Incidence of dysphagia after stroke >80%

CCTRT for HN cancer 45% incidence of prolonged

feeding tube-dependent dysphagia and an incidence
rate for aspiration of 59%

Complications of dysphagia include malnutrition,

dehydration, aspiration, pneumonia, pulmonary
10
abscess, and death
FEES
Instrumental assessment of deglutive function using
a Flexible Laryngoscope to view Pharyngeal &
Laryngeal Structures immediately BEFORE & AFTER
a swallow

Flexible Laryngoscope 1968

1988- Langmore et al Comprehensive assessment of

swallowing using a Fiberoptic Laryngoscope

The name FEES- Generic signifier for a variety of

Endoscopic examinations of swallowing described
since that time
Purpose of FEES
Visualising laryngopharyngeal structures

Assessing laryngopharyngeal sensation

Assessing secretion management

Assessing patients at high risk of aspiration

Assessing swallowing of specific foods

Assessing swallow fatigue over time

Assessing patients who cannot undergo videofluoroscopy (due to immobility,

equipment or medical instability)

Biofeedback/teaching

Repeated assessment
Suitability of FEES-Non Exhaustive list
Indications Exercise caution:

Acquired neurological disorders Severe movement

Traumatic brain injury disorders and/or severe
Benign/ Malignant head and agitation
neck disorders Base of skull/facial
Critical care patients: fracture
Tracheostomized/ventilated Recent history of
patients
Respiratory disorders
severe/life-threatening
Spinally injured epistaxis
Neuro-degenerative Sino-nasal and anterior
Burns and trauma skull base
General medical tumours/surgery
Elderly Nasopharyngeal stenosis
Equipment
Technique
Written Informed Consent

Position

Avoid Topical Nasal

Anesthesia

Endoscope passed through

more patent nasal cavity
Pre Swallow Position
Advance tip of Endoscope
to a position between Soft
palate and tip of
Epiglottis

BOT/ Valecullae/
Larynx/ Both PFS

HOME position

Allows visualization of
Bolus transit prior to
swallow initiation
WHITEOUT
During BOT/ Velum contact PPW

the
height
Distal tip of endoscope
of trapped transiently against
swallow PPW by velum/BOT

Light projected from the tip

of the scope reflects off of
Prior to whiteout, BOT &
the tissue it is in contact Immediately
Epiglottis advance
with after
towards PPW/
Appears as a flash of light Lateral Pharyngeal walls whiteout-
lasting approx one half of begin to medialize/ Epiglottis is
a second seen to return
Arytenoids medialize from its
and begin to tilt inverted
anteriorly- position back
Bolus cannot be visualized
Signalling onset of to its resting
swallow position
Post Swallow position
Following swallow- endoscope is
advanced into the laryngeal
vestibule

Larynx/ Subglottis/ Anterior

tracheal wall

Allows for detection of any

laryngeal penetration and/or
aspiration

Following this close inspection-

Endoscope is then retracted to
Pre swallow position to prepare
for any subsequent bolus
advancement
FEES Protocol
Anatomy and Dry Swallow
Physiology of Cough/throat clearing
laryngopharyngeal Hold breadth and cough
structures Phonation of /ee/
Strained high pitched phonation /ee/
Bolus presentation Thin liquid
Thick liquid
Semi solid
Soft solid
Compensatory Effortful swallow/ Postural
techniques modifications

Therapeutic maneuvers (After initiation of swallow therapy)

Findings from FEES
No single standardized system for
scoring findings of FEES exam

In a gross sense, characterize

Timing
Safety
Efficiency of swallow

Objective observations begin prior to

the presentation of food or liquid
SECRETION RATING (Murray 1999)
0 Normal rating: No
visible secretions in
pharynx
1 Bilateral or pooled
secretions
2 Any secretions that
change from 1 to a 3
rating during the
observation period
3 Most severe rating:
Secretions seen in the
laryngeal vestibule
Pharyngeal residue
Penetration
Aspiration
Aspiration
SILENT ASPIRATION
Aspiration occurring with no signs
(In case of sensory loss to pharynx & larynx)

Occurring May be secondary to

Pre swallow Pharyngeal pooling
During Inadequate true vocal fold
swallow closure
Postswallow Oral residual
Pharyngeal residual
Penetration Aspiration Scale (Rosenbek 1996)

1 Material does not enter the airway

2 Material enters the airway, remains above vocal folds and is ejected from
the airway

3 Material enters the airway, remains above vocal folds, and is not ejected
from the airway

4 Most severe rating: Secretions seen in the laryngeal vestibule

5 Material enters the airway, contacts vocal folds, and is not ejected from the
airway

6 Material enters the airway, passes below vocal folds, and is ejected into the
larynx or out of the airway

7 Material enters the airway, passes below vocal folds, and is not ejected from
the trachea despite effort

8 Material enters the airway, passes below vocal folds, and no effort is made
to eject
Therapeutic
Observe effects of therapy techniques on physiology of swallowing

Compensatory Techniques Facilitative Techniques

Postural Modification Swallowing Maneuvers
Increasing sensory input
Modifying volume and Rehabilitation Exercises:
speed of food Oromotor
presentation Pharyngeal
Changing food Laryngeal
consistency or viscosity

FEES can be used to provide biofeedback to patient

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Rehabilitation Exercise
Therapeutic
Effortful swallow

Mendelson Maneuver

Shaker (head--lifting) Exercises

Modified Shakers exercises

Vocal adduction exercises

Vocal function Exercises

Conclusion

Comprehensive evaluation of the oropharyngeal phase

of swallowing that can reveal the nature of the problem
and guide management, improving efficacy and outcome.

Biofeedback tool in therapy.

Safe, valid, and reliable procedure that can be used in

patient populations, in different settings, and for different
purposes

[Langmore, 2006)
THANK YOU