Medical Literature

Literature Supporting the Need for Instrumental Swallow Evaluations

  1. Bedside clinical swallow exams by SLPs have proven to be under-estimating and over-estimating aspiration; therefore, the use of instrumental swallow evaluations is imperative.
  2. SLPs ability to determine swallow physiology, presence of penetration/aspiration, and applicable tx targets is low.
  3. There are certain risk factors in the SNF population that are predictors of aspiration pneumonia.
  4. Instrumentals swallow evaluations help to reduce Medicare costs associated with re-hospitalizations.
  • Brates, D., Molfenter, S. M., & Thibeault, S. L. (2019). Assessing hyolaryngeal excursion: comparing quantitative methods to palpation at the bedside and visualization during videofluoroscopy. Dysphagia, 34(3), 298-307.
  • Vose, Alisha. A Survey of Clinical Decision Making When Identifying Swallowing Impairments and Determining Treatment. JSLHR Volume 61 Issue 11. November 2018, 2735-2756.
  • Attrill, S., White, S., Murray, J., Hammond, S., Doeltgen, S. (2018).  Impact of oropharyngeal dysphagia on healthcare cost and legnth of stay in hospital: a systematic review.  BMC Health Serv Res. 2018 Aug 2;18(1):594.
  • Miles A, McFarlane M, Scott S, Hunting A. Cough response to aspiration in thin and thick fluids during FEES in hospitalized inpatients. Int J Lang Commun Disord. 2018 Sep;53(5):909-918. doi: 10.1111/1460-6984.12401. Epub 2018 May 30. PMID: 29845700.
  • Vose, A.K., Kesneck, S., Sunday, K., Plowman, E., & Humbert, I. (2018). A survey of clinician decision making when identifying swallowing impairments and identifying treatment. AJSLHR 61(11), 2735-2756.
  • Marian, Thomas et al. “Measurement of Oxygen Desaturation Is Not Useful for the Detection of Aspiration in Dysphagic Stroke Patients.” Cerebrovascular diseases extra vol. 7,1 (2017): 44-50
  • Lagarde, M. L., Kamalski, D. M., & Van Den Engel-Hoek, L. E. N. I. E. (2016). The reliability and validity of cervical auscultation in the diagnosis of dysphagia: a systematic review. Clinical rehabilitation, 30(2), 199-207.
  • Leder, S.B. (2015). Comparing Simultaneous Clinical Swallow Evaluations and Fiberoptic Endoscopic Evaluations of Swallowing: Findings and Consequences. Perspectives on Swallowing and Swallowing Disorders (Dysphagia). ASHA Volume 24, February 2015.
  • Barrett, E. Bandur, D. (2014).  Shift in practice: Evaluating the impact of fiberoptic endoscopic evaluations of swallowing (FEES) in Canadian acute tertiary care setting. Presented at DRS 2014.
  • Crary MA, Carnaby GD, Sia I, Khanna A, Waters MF. Spontaneous swallowing frequency has potential to identify dysphagia in acute stroke. Stroke. 2013;44(12):3452-3457. doi:10.1161/ STROKEAHA.113.003048
  • Leder, S.B., Suiter, D.M., Duffey, D. & Judson, B.L. (2012). Vocal fold immobility and aspiration status: A direct replication study. Dysphagia, 27, 265-270
  • Jencks, SF, Williams, MV, Coleman EA.  (2006). Rehospitalizations among patients in the Medicare fee-for-service program. N ERngl J Med 2009;60:1418-28.
  • Gerrie J.J.W. Bours, Rene´e Speyer, Jessie Lemmens, Martien Limburg & Rianne de Wit. Bedside screening tests vs. videofluoroscopy or fibreoptic endoscopic evaluation of swallowing to detect dysphagia in patients with neurological disorders: systematic review. Journal of Advanced Nursing. Oct 2008; 477-493.
  • Langmore, S.E., Skarupski, K.A., Park, P.S., Fries, B.E. Predictors of aspiration pneumonia in nursing home residents. Dysphagia. 2002; 10.1007/s00455-002-0072-1.
  • Leder, S.B., Espinosa, M.S. Aspiration risk after acute stroke: comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing. Dysphagia. 2002; 17:214-218.
  • Smith CH, Logemann JA, Colangelo LA, Rademaker AW, Pauloski BR. Incidence and patient characteristics associated with silent aspiration in the acute care setting. Dysphagia 1999; 14:1-7.
  • Langmore, SE, Terpenning, MS, Schork, A, Chen, Y, Murray, JT, Lopatin, D, Loesche, WJ. (1998). Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia, 13(2), 69-81.
  • Smithard, D.G., O’Neill, P.A., Park, C., et al. Can bedside assessment reliably exclude aspiration following acute stroke? Age and Ageing. 1998;27i(2), 99-106.
  • Leder, SB. Videofluoroscopic evaluation of aspiration with visual examination of the gag reflex and velar movement. Dysphagia. 1997 Winter;12(1):21-3.
  • Murray, J, Langmore, S.E., Ginsberg, S. & Dostie, A.(1996). The significance of oropharyngeal secretions and swallowing frequency in predicting aspiration. Dysphagia, 11, 99-103.
  • Langmore, S.E. & Logemann, J.A. (1991). After the clinical bedside swallowing examination: What next? AJSLP, September, 13-20.
  • https://leader.pubs.asha.org/do/10.1044/leader.FTR1.26062021.46/full/ (Title: Speak the SNF Lingo to show the Need For Instrumental Assessments)
  • https://www.asha.org/practice-portal/clinical-topics/adult-dysphagia/#collapse_2. Accessed 8/4/2021 (Title: Adult Dysphagia)

 

Literature Comparing Efficacy of Endoscopic, Fluoroscopic, and Clinical Swallow Evaluations 

  1. Studies show there is a good agreement between MBSS and FEES when examining premature spillage, pharyngeal residue, laryngeal penetration, and tracheal aspiration.
  2. FEES has proven to be as sensitive as or more sensitive than the MBSS relative to standard swallowing parameters.
  3. Barium concentrations used during MBSS have low palatability scores, increased swallow timing parameters, and is harmful to the lungs.
  4. Based on research, MBSS and FEES are both imperfect exams, both have benefits and limitations, yet both are in high agreement with one another for identifying penetration, aspiration, and providing recommendations.
  • Giraldo-Cadavid, L.F., Leal-Leañp, L. R., Leon-Basantes, G.A., Garcia, R., Ovalle, S., Abondano-Garavito, J. E. (2017) Accuracy of endocopcic and video fluoroscopic evaluations of swallowing for oropharyngeal dysphagia. Laryngoscope, Laryngoscope, 127:2002–2010.
  • Pisenga, J. M. and Langmore, S.E. (2016). Parameters of instrumental swallowing disorders: describing a diagnostic dilemma. Dysphagia June 2016, Volume 31, Issue 3 pp 462–472
  • Dietsch, A.M., Solomon, N.P., Steele, C.M., Pelletier, C.A. The effect of barium on perceptions of taste intensity and palatability. Dysphagia. 2013.
  • Stokely, S.L., Molfenter, S.M., Steele, C.M. Effects of barium concentration on oropharyngeal swallow timing measures. Dysphagia. 2013.
  • Ekberg, O, M. Bülow, S. Ekman, G. Hall, M. Stading & K. Wendin (2009) Effect of Barium Sulfate Contrast Medium on Rheology and Sensory Texture Attributes in a Model Food, Acta Radiologica, 50:2, 131-138
  • Leder, S.B., Murray, J.T. Fiberoptic endoscopic evaluation of swallowing. Physical Medicine & Rehabilitation Clinics of North America. Nov 2008;19(4):787-801.
  • Kelly, A.M. Assessing penetration and aspiration: How do videofluoroscopy and fiberoptic endoscopic evaluation of swallowing compare? Laryngoscope. 2007;117, 1732-1727.
  • Kelly, A.M., Leslie, P., Beale, T, et al. (2006). Assessing endoscopic evaluation of swallowing and videofluoroscopy: Does examination type influence perception of pharyngeal severity? Clinical Otolaryngol, 31, 425-432.
  • Rao N., Brady, S. L., Chaudhuri, G., Donselli J. J., & Wesling, M. W. (2003/2006). Gold-standard? Analysis of the videofluoroscopic and fiberoptic endoscopic swallow examinations. Journal of Applied Research, 3(1), 89-96.
  • Langmore, S. E. (2001). Endoscopic evaluation and treatment of swallowing disorders. New York: Thieme
  • Aviv, J.E. Prospective, randomized outcome study of endoscopy vs. modified barium swallow in patients with dysphagia. Laryngoscope. 2000; 100, 563-574.
  • Madden, C., Fenton, J., Hughes, J., & Timon, C. (2000). Comparison between videofluoroscopy and milk-swallow endoscopy in the assessment of swallowing function. Clinical Otolaryngology, 25(6), 504-506.
  • Logemann, J. A., Rademaker, A. W., Pauloski, B. R., Ohmae, Y., & Kahrilas, P. J. (1998). Normal swallowing physiology as viewed by videoflouroscopy and videoendoscopy. Folia Phoniatria et Logopaedica, 50, 311-319.
  • Leder, S.B., Sasaki, C.T., Burrell, M.I. (1998).  Fiberoptic endoscopic evaluation of dysphagia to identify silent aspiratoin. Dysphagia, 13, 19-21.
  • Crary, M.A., Baron, J.  Endoscopic and Fluoroscopic Evaluations of Swallowing: Comparison of Observed and Inferred Findings.  Dysphagia. 1997;12(2).
  • Wu, C.H., Hsiao, T.Y., Chen, J.C., Chang, Y.C., &Lee, S.Y. Evaluation of swallowing safety with fiberoptic endoscope: Comparison with video fluoroscopic technique.  Laryngoscope. 1997;107, 396-401.
  • Murray, J., Langmore, S. E., Ginsberg, S., & Dostie, A. (1996). The significance of accumulated oropharyngeal secretions and swallowing frequency in predicting aspiration. Dysphagia, 11(2), 99-103.
  • Bastian R.  Video endoscopic evaluation of patients with dysphagia:  an adjunct to the modified barium swallow.  Otolaryngology Head & Neck Surgery; 1991. 104(3):339-50.
  • Langmore, S.E., Schatz, K., & Olsen, N.  Endoscopic and video fluoroscopic evaluations of swallowing and aspiration.  Annals of Otology, Rhinology & Laryngology. 1991;100(8), 678-681.

 

Literature on Some Benefits of FEES

  1. Evidence of aspiration/penetration after the swallow, over time, and the fatigue factor can impact swallow function and be appreciated to a greater level on FEES because the recording lasts longer than an MBSS.
  2. The direct visualization, in color, of anatomy during FEES allows for assessment of tissue and muscle function, anatomical variants and abnormalities, and proves insight into the true etiology for the dysphagia.
  3. FEES has proven to be the ideal assessment of vocal cord function, airway closure, and saliva management…all high risk factors for aspiration pneumonia.
  4. FEES allows the clinician to observe the breathing/swallowing coordination, the transition from breathing to apnea during swallowing to breathing again.
  5. Per literature, aspiration occurs about 25% of the time BEFORE the swallow, about 7% DURING the swallow, and about 65% AFTER the swallow.  Each type of instrumental swallow exam can miss parts of the swallow.  Continous recording of FEES versus x-ray being turned on/off is why FEES is more sensitive compared to MBSS.
  • Langmore, SE, Scarborough, DR, Kelchner, LN, Swigert, NB, Murray, J, Reece, S, Cavanagh, T, Harrigan, LC, Scheel, R, M Gosa, MM, Rule DK. Tutorial on Clinical Practice for Use of the Fiberoptic Endoscopic Evaluation of Swallowing Procedure with Adult Populations: Part 1. AJSLP 2022, 31 (1) 163-187
  • Langmore. S.E. (2017). History of fiberoptic endoscopic evaluation of swallowing for evaluation and management of pharyngeal dysphagia: changes over the years. Dysphagia 32 (1): 27-38
  • Takahashi, N, Kikutani, T, Tamura, F., Groher, M., & Kuboki, T. Videoendoscopic assessment of swallowing function to predict the future incidence of pneumonia of the elderly. Journal of Oral Rehabilitation. 2012; 39; 429-437.
  • Butler, S.G., Maslan, J., Stuart, A., Leng, X., Wilhelm, E., Lintzenich, C.R., Williamson, J., & Kritchevsky, S.B. (2011). Factors influencing bolus dwell times in healthy older adults assessed endoscopically.  Laryngoscope, Dec; 121(12): 2526-34.
  • Allen, J.E., White, C.J., Leonard, R.J., Belafsky, P.C> Prevalence of penetration and aspiration on videofluoroscopy in normal individuals without dysphagia.  Journal of Otolaryngology Head and Neck Surgery. Feb 2010; 142(2): 208-13.
  • Warnecke, T., Ritter, M.A., Kroger, B., Oelenberg, S., Teismann, I., Heuschmann, P.U., Ringelstein, E.B., Nabavi, D.G., Dziewas, R. Fiberoptic endoscopic dysphagia severity scale predicts outcome after acute stroke. Cerebrovascular Disease. July 2009;28(3):283-9
  • Langmore, S., Endoscopic Evaluation and Treatment of Swallowing Disorders. 2001; 120,125.131.Aviv, J.E. Prospective, randomized outcome study of endoscopy vs. modified barium swallow in patients with dysphagia. Laryngoscope. 2000; 100, 563-574.
  • Leder, S.B. & Sasaki, C.T. (2001). Use of FEES to assess and manage patients with head and neck cancer. In Langmore, S.E., editor. Endoscopic evaluation and treatment of swallowing disorders. New York: Thieme; 201-212.
  • Smith, C.H., Logemann, J.A., Colangelo, L.A., Rademaker, A.W., Pauloski, B.R. Incidence and patient characteristics associated with silent aspiration in the acute care setting. Dysphagia. 1999; 14: 1-7.
  • McCulloch T.M., Langmore S.E., Palmer P.M, Jaffe D. Timing of glossopharyngeal events during swallow: a combined electromyographic and endoscopic evaluation. Dysphagia. 1998;13:123.
  • McCulloch T.M., Langmore S.E., Palmer P.M. Timing of glottis closure during swallow: a combined electromyographic and endoscopic evaluation. Dysphagia. 1997;12:111.
  • Murray, J., Langmore, S.E., Ginsberg, S., & Dostie, A. The significance of accumulated oropharyngeal secretions and swallowing frequency in predicting aspiration.  Dysphagia 1996; 11:99-103.
  • https://sdx-dysphagia-experts.net/2016/06/20/the-proof-is-the-pudding-part-1/  The Proof Is In The Pudding: A Tribute to Steven Leder & His Contributions to FEES Part 1, 2, and 3 by Karen Sheffler, MS, CCC-SLP, BCS-S

 

Literature Examining Safety of FEES

  1. Of the potential risks associated with FEES endoscopy, including epistaxis, laryngospasm, and vasovagal response; a mild case of epistaxis is the most prevalent and does not gernally prevent completion of the exam.
  2. The rate of complications associated with FEES is less than 1% overall.
  3. FEES has proven to be a safe and well tolerated method of assessing swallow function when performed by a trained Speech Language Pathologist (see Links and Competency Training sections of this website for more info).
  • Dziewas et al. Safety and Clinical Impact of FEES – Results of the FEES-Registry. Neurological Research and Practice (2019) 1:16
  • Nacci A, Matteucci J, Romeo SO, Santopadre S, Cavaliere MD, Barillari MR, Berrettini S, Fattori B.; 2016. Complications with Fiberoptic Endoscopic Evaluation of Swallowing in 2,820 Examinations. ENT, Audiology and Phoniatrics Unit, Department of Neurosciences, University of Pisa, Italy. Folia Phoniatr Logop. 2016;68(1):37-45. doi: 10.1159/000446985. Epub 2016 Jul 26.
  • Warnecke, T., Teismann, I., Oslenber, S., Hamacher, C., Ringelstein, E.B., Schabitz, W.R., & Dziewas, R.; 2009. The safety of fiberoptic endoscopic evaluation of swallowing in acute stroke patients. Retrieved July 18, 2009 from www.stroke.ahajournals.org.
  • Suiter, D. M., & Moorhead, M. K. (2007). Effects of flexible fiberoptic endoscopy on pharyngeal swallow physiology. Otolaryngology–Head and Neck Surgery, 137(6), 956–958.
  • Aviv, J.E., Murray, T., Zschommler, A., Cohen, M., Gartner, C.  Flexible endoscopic evaluation of swallowing with sensory testing: patient characteristics and analysis of safety in 1340 consecutive examinations.  Annals of Otology, Rhinology & Laryngology. 2005;114:173-176.
  • Cohen, M.A., Setzen, M., Perlman, P.W., Ditkoff, M., Mattucci, K.F., Guss, J.  The safety of flexible endoscopic evaluation of swallowing with sensory testing in an outpatient otolaryngology setting.  Laryngoscope.  2003;113:21-24.
  • Langmore, S., Endoscopic Evaluation and Treatment of Swallowing Disorders. 2001; 120,125.131.Aviv, J.E. Prospective, randomized outcome study of endoscopy vs. modified barium swallow in patients with dysphagia. Laryngoscope. 2000; 100, 563-574.
  • Aviv, J.E., Kaplan, S.T., Thompson, J.E., Spitzer, J., Diamond, B., Close, L.G.  The safety of flexible endoscopic evaluation of swallowing with sensory testing: an analysis of 500 consecutive evaluations. Dysphagia. 2000;15:39-44.
  • Wu, C.H., Hsiao, T.Y., Chen, J.C., Chang, Y.C., &Lee, S.Y. Evaluation of swallowing safety with fiberoptic endoscope: Comparison with video fluoroscopic technique.  Laryngoscope. 1997; 107, 396-401.
  • Langmore SE, Pelletier C, Nelson R.  Results of FEES survey on safety of endoscopy for swallowing assessment.  Presented at Fourth Annual Meeting of the Dysphagia Research Society. McLean. VA. October 28, 1995.

 

Literature Addressing Patient Comfort and Whether or Not to Use Anesthesia with FEES

  1. Studies show that endoscope placement does not adversely affect swallow function.
  2. When SLPs perform FEES, the incidence of complications and pt intolerance is minimal therefore anesthesia is not needed. 
  3. Low levels of lidocaine (up to .5 ml of up to 4% hydrolidocaine gel within the nose) can enhance exam tolerability without negatively impacting swallow scores. 
  4. Higher levels of topical anesthesia or vasoconstrictors may lead to an increase in penetration/aspiration scores.
  • O’Dea, Meredith B., Langmore, Susan E., Krisciunas, Gintas P., Walsh, Michael, Zanchetti, Linsey L., Scheel, Rebecca, McNally, Edell, Kaneoka, Asako Satoh, Guarino, Anthony J., Butler, Susan G. (2015)  Effect of Lidocaine on Swallowing During FEES in Patients With Dysphagia. Annals of Otology, Rhinology & Laryngology, Vol. 124(7) 537–544
  • Kamarunas, E.E., McCullough, G.H., Guidry, T.J., Mennemeier, M. & Schluteman, K. (2014). Effects of topical nasal anesthetic on Fiberoptic Endoscopic Examination of Swallowing with Sensory Testing (FEESST).Dysphagia, 29 (1), 33-43.
  • Fife, T., Butler, S., Langmore, S., Lester, S., Wright, C., Kemp, S., Grace-Martin, K., Rees, C. (2014). Use of topical nasal anesthesia during flexible endoscopic evaluation of swallowing in dysphagia patients. Ann Otol Rhinol Laryngol. DOI: 10.1177/0003489414550153.
  • Kamarunas, E.E., McCullough, G.H., Guidry, T.J., Mennemeier, M., Schulterman, K. Effects of topical nasal anesthetic on fiberoptic endoscopic examination of swallowing with sensory testing. Dysphagia. July 2013.
  • Lester, S., Langmore, S.E., Lintzenich, C.R., Wright, S.C., Grace-Martin, K., Fife, T., Butler, S.G. The effects of topical anesthetic on swallowing during nasoendoscopy. Laryngoscope. July 2013; 123(7):1704-8.
  • Suiter, D. M., & Moorhead, M. K. Effects of flexible fiberoptic endoscopy on pharyngeal swallow physiology. Otolaryngology-Head and Neck Surgery. 2007;956-858.
  • Singh, V., Brockbank, M.J., & Todd, G.B. Swallowing and sensation: Evaluation of deglutition in the anesthetized larynx. Annals of Otology, Rhinology & Laryngology. 2002, 111, 291-294.
  • Leder, S.B., Ross, D.A., Briskin, K.B., Sasaki, C.T.  A prospective, double-blind, randomized study on the use of a topical anesthetic, vasoconstrictor, and placebo during transnasal flexible fiberoptic endoscopy.  Journal of Speech, Language and Hearing Research.  1997;40:1352-1357.
  • Singh, V., Brockbank, M.J., Todd, G.B.  Flexible transnasal endoscopy: is local anesthetic necessary?  Journal of Laryngology and Otology.  1997;111:616-618

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