FEES
VFSS
View
Superior view of the pharynx and larynx
Sagittal view of the head and neck
Anatomy
Full color images of the hypopharynx and larynx
Gray-scale images obtained including structures in the oral cavity, pharynx, and cervical esophagus
Contrast
Green/blue/white food dye
Barium
May also use barium
Swallow
Able to view pharyngeal phase except for brief (less than 1 s) “white out” during height of swallow. Unable to view oral phase or esophageal phase
Comprehensive view of all swallowing phases – oral, pharyngeal, cervical esophageal phases
FEES has been found to be equally or more sensitive than the VFSS in detecting parameters of swallow dysfunction such as penetration, aspiration, and pharyngeal residue [3, 14–16]. Assessment with FEES yields more accurate identification of anatomical markers and assessment of the location of pharyngeal residue [16]. FEES has been found to be equally effective and valuable compared to the VFSS for evaluation of swallowing [3] but may not be interchangeable, as FEES has been shown to yield higher penetration-aspiration scores and more severe ratings of residue [14, 15]. Guidance regarding diet and health outcomes after the FEES and VFSS have been found to be comparable [16].
Patient selection for FEES
Best candidates | Less ideal candidates | Not candidates |
|---|---|---|
Breastfed infants Unable to transport from bedside Cranial nerve involvement Pre-and-post upper airway surgery Require assessment of laryngeal/pharyngeal sensation and secretion management Concerns for frequent radiation exposure Require specialized positioning that is not possible in fluoroscopy Limited volume of oral intake (assess readiness for initiation or progression of oral feeding) Require additional time for comprehensive exam that is not possible in fluoroscopy | Toddlers Behavior challenges Oral sensory deficits/oral aversion Infants with laryngomalacia Infants with good coordination of suck-swallow-breathe sequence (frequent “white out”) Retrognathia | Nasal obstruction Choanal atresia Pharyngeal stenosis Bleeding disorders Severe sensory or behavioral disorders |
Safety, Use of Topical Nasal Anesthetic, and Contrast Material
FEES has been established as a safe exam across the age span in multiple studies [1, 17], including in preterm infants in the NICU [13] and breastfeeding infants [11]. The most commonly reported adverse effects of FEES reported in the literature are epistaxis, vasovagal response, and laryngospasm; however, these are rarely seen. The acuity of patient population must be considered when determining the safety measures that should be in place for FEES. Additionally, careful consideration should be given to whether a FEES should be completed in patients who are acutely ill or medically fragile [18].
The use of topical anesthetic in FEES has been studied in adults, but not specifically in children. In the pediatric population, use of topical anesthetic should be avoided for children with severe neurologic compromise and infants younger than 12 months due to concerns with alteration of laryngeal sensation and potential impact on swallowing function [19, 20]. At this time, there are no published data to guide dosage, concentration, or delivery method of topical anesthetic for children during FEES. When possible, patient comfort during the FEES should be optimized using alternative strategies, including close parent/caregiver participation and support.
Contrast materials that can be considered for use during FEES include green, blue, or white food coloring or liquid barium. There are varying reports in the literature about the utility of contrast material to improve visualization of the pathway of the bolus [21–23]. In breastfeeding infants, contrast material may be swabbed into the infant’s oral cavity [11] and/or on the mother’s nipple prior to the initiation of breastfeeding; however, contrast may only be visible for the initial few boluses.
Roles of Team Members
Roles of team members in FEES
FEES team member | Role |
|---|---|
Speech-language pathologist | Screening of communication/cognitive status; oral peripheral exam; evaluation of pharyngeal and laryngeal vocal and swallowing function; determination of appropriate adaptations to improve the safety and efficiency of feeding and swallowing function; in some settings, SLP passes and positions the endoscope |
Otolaryngologist (ENT) | Evaluation of ENT health/status; passing and positioning of endoscope; evaluation of pharyngeal and laryngeal structure and function; participation in determining the post-exam feeding plan and making appropriate referrals |
Occupational therapist (OT) | Evaluation of motor development, sensory processing, oral motor skills, oral sensory processing, and positioning needs relevant to feeding/swallowing function; positions parent and parent/child; assists with feeding patient during the assessment; determination of appropriate adaptations to improve the safety and efficiency of feeding and swallowing function |
Nurse | Collection of vitals and medical intake, assists in positioning/supporting patient during the evaluation, including stabilization of the patient’s head to prevent excessive movement |
Registered dietitian | Evaluation of patient’s nutrition status; provision of diet recommendations that optimize nutrition based on swallow study results |
Child life specialist | Preparation of patient and family for evaluation; may share social stories or demonstrate the exam on a doll; supports patient and family during the evaluation and may suggest strategies for calming and/or alternate focus (stress balls, watching a video, etc.) |
Lactation consultant | Supports the mother-baby pair in the process of breastfeeding; prevents, recognizes, and solves breastfeeding difficulties |
Parents/caregivers | Educates staff on their child’s current diet and feeding/swallowing challenges; provides insight into home strategies used to decrease child’s stress; verbalizes family’s goals and priorities and child’s medical history |
Child | Eat, swallow, vocalize, and participate in the most typical feeding possible |
Speech-Language Pathologist Approach
The Set Up: Preparing for Pediatric FEES
FEES is a functional exam and is most effective when swallowing is visualized in the closest approximation to the patient’s typical feeding, including preferred foods and liquids, modalities for eating and drinking, and rate of consumption. Planning and preparation need to occur among team members in collaboration with the patient and caregivers. Organization and environmental supports lay the foundation for a successful clinic visit.
Parent/Patient Preparation
Understanding the purpose of FEES and what will happen during and after the appointment is important for parent/caregiver and the child (if developmentally appropriate) prior to FEES. Caregivers are encouraged to bring the child’s familiar feeding items (cups, utensils, etc.), items that are calming and soothing (e.g., pacifier, music), and preferred foods and liquids. Team members discuss with parents/caregivers whether they feel the child will be able to tolerate the exam and how the team can support the child’s successful participation.
For older children, a practice FEES therapy session with the clinician and/or the child life specialist prior to the exam can be useful to provide exposure to the equipment, setting, and personnel for FEES. Providing a social story can prepare a child for what to expect. Practicing some parts of the exam such as drinking liquids colored with blue food dye at home may be helpful. Establishing a behavioral reinforcement system (e.g., star chart for number of swallows) or providing an incentive can improve a child’s motivation to participate. If appropriate, directing a child’s attention to his/her exam images may benefit the child’s level of engagement as well as provide an opportunity for biofeedback.
Setting Up the Environment
To optimize success and efficiency, it is critical that all food/liquid consistencies, cups, and bottle and feeding utensils are prepared, labeled, and easily accessible before the exam begins. Team members who are present during the exam must bring a calm, attentive, and cooperative attitude. The environment should support patient participation with minimal distraction, calming, and soothing items for the patient. Prior to the exam, infants may benefit from having access to sucrose and non-nutritive sucking, which have been shown to have analgesic properties for neonates, particularly when offered together [24].
Positioning
Setup for breastfeeding FEES
The Examination
Goals
It is critical to establish goals for what the team considers an “adequate” FEES as well as individualized FEES goals for each patient. The child’s age, level of development, compliance, and past feeding experience all influence what is able to be observed. A prescribed protocol may or may not be possible. Modifications of vocal and swallowing tasks are often required to optimize efficiency of exam and patient compliance.
Oral Mechanism Exam
Prior to introducing foods or liquids during the endoscopic exam, assessment of facial and oral motor structures and function is critical as part of a comprehensive feeding and swallowing examination [31]. In this assessment, the clinician may evaluate resting posture and tone of oral and facial structures, dental occlusion and dental eruption, and range of motion and coordination of facial and oral motor structures as part of the cranial nerve exam. Non-nutritive oral skills as well as observations of patient’s vocal quality, pitch, and loudness are obtained. These observations will inform decision-making regarding which foods or liquids are offered and what modality to use (i.e. open cup, straw) during FEES.
Global and Oral Sensory Processing
In preparation for FEES, the child’s global and oral sensory processing function is considered. Exam activities are tailored to achieve a state of arousal supportive of feeding and participation during the exam [32]. Clinicians consider oral sensory processing challenges including hyposensitivity, hypersensitivity, or both when providing modifications during bolus presentation for FEES. Environmental modifications that can be made include reduced lighting, minimizing external distractions, or swaddling to help calm and organize the sensory system and maximize patient participation in the FEES [32].
Oral Motor Observations of Feeding
“Home position” with anatomic structures labeled
Assessment of Pharyngeal and Laryngeal Structure and Function
Nasal Structures and Nasopharynx
A patent nasal passage is required for FEES. Selection of passing the endoscope through the right or left nare is directly impacted by the presence or absence of nasal obstruction. When a nasogastric tube is in place, the team needs to decide to remove the tube, pass the endoscope around the tube, or pass the endoscope in the contralateral nare. The speech-language pathologist may provide assessment of the velopharyngeal mechanism during speech tasks if there are concerns with resonance and/or nasopharyngeal regurgitation.
Secretion Management
Prior to introducing a bolus, the team evaluates standing secretions in the hypopharynx, looking for the presence/absence, volume, location, color, and viscosity of secretions. The team can assess volitional or spontaneous ability to clear standing secretions. These observations contribute to understanding of the child’s global swallow function, determination of risk of aspiration, and inference of pharyngeal swallow function for the patient’s current diet [2, 33, 34].
Vocal Tasks
Vocal tasks elicited during FEES will vary pending vocal concerns and patient’s developmental level. During vocal tasks, one can infer cranial nerve involvement and appreciate symmetry, strength, range of motion, and coordination of pharyngeal and laryngeal structures.
Pharyngeal and Laryngeal Sensory Testing
Reduced laryngopharyngeal sensory capacity has been shown to be correlated with penetration, aspiration, history of pneumonia, neurological disease, and reflux [35]. Indirect assessment of pharyngeal and laryngeal sensation can be completed given symptoms of deep laryngeal penetration or aspiration without cough, presence of pharyngeal residue that is not perceived or spontaneously cleared by the patient, or minimal response to the presence of the endoscope.
Pharyngeal Swallowing
- 1.
Initiation of pharyngeal swallow: Anatomical markers are used in determining the location of pharyngeal swallow initiation, including base of the tongue, valleculae, and pyriform sinuses (Fig. 18.2). As the bolus enters the pharynx, clinicians visualize where the bolus is held prior to the swallow as well as timeliness of initiation of the swallow. The pattern of bolus flow (lateral channels, right vs left, central) is also directly viewed. Risk to airway protection can be directly assessed by observing the bolus in instances of delay in initiation of the pharyngeal swallow.
- 2.
Laryngeal penetration: Presence or absence of laryngeal penetration, when laryngeal penetration occurred (before, during, after swallow), and depth of penetration in the laryngeal vestibule are determined. Challenges in determining the depth of penetration are present due to “white out,” especially during FEES with infants with rapid consecutive swallows. Examiners can most reliably assess presence/absence and depth of laryngeal penetration if occurring before or after the swallow.
- 3.
Aspiration: Aspiration can be directly viewed. However, “white out” occurs during the height of the swallow when pharyngeal musculature constricts around the endoscope, lasting approximately less than 1 second. If aspiration occurs before the swallow or after the swallow, images can directly confirm aspiration. Presence or absence of aspiration can also be assessed based on post-swallow residue. Examiners assess the presence/absence, timeliness, and effectiveness of a cough in response to the aspiration event.
- 4.
Residue: After the pharyngeal swallow, bolus residue patterns can be assessed. Presence or absence of pharyngeal residue, location of pharyngeal residue using anatomical markers, and the amount of residue are evaluated. In the literature, there are standardized and validated residue severity rating scales designed for use in FEES [36, 37] but are not designed with intended use for pediatric patients.
- 5.
Upper esophageal sphincter (UES): The UES inlet is viewed, but images obtained do not allow complete visualization of the bolus passing through the pharyngeal-esophageal segment. UES function is not able to be directly assessed. If there is concern regarding UES dysfunction, other diagnostic exams (e.g., upper GI, esophagram, VFSS, manometry) may be recommended.
- 6.
Nasopharyngeal regurgitation: Instances of nasopharyngeal regurgitation are typically not able to be directly viewed given position of the endoscope during FEES. However, if there are concerns for nasopharyngeal regurgitation, the endoscopist may position the tip of the endoscope in the nasopharynx to determine presence or absence of post-swallow bolus residue.
- 7.
Compensatory strategies: Both direct and indirect compensatory strategies may be trialed based on the patient’s symptoms. Indirect strategies include modifications to bolus size and bolus flow (change to nipple flow rate, sipper cup with or without valve in place, etc.), changes to the position of the patient, type of positional supports in place, or changes to viscosity of liquids presented [38]. Direct compensatory strategies may be used, but implementation of strategies is impacted by the age and/or developmental level of the pediatric patient. Trial of compensatory swallow strategies or swallow maneuvers is an ideal time to utilize FEES as a biofeedback tool, both to build patient awareness of dysphagia symptoms and also to visualize success of strategies trialed (Tables 18.4 and 18.5).
Presence of liquid in nasal passages
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