JCPSLP Vol 14 No 1 2012

Professional issues

Fibreoptic Endoscopic Evaluation of Swallowing (FEES) Models of service delivery and approaches to training Michelle Cimoli and Joanne Sweeney

Fibreoptic Endoscopic Evaluation of Swallowing (FEES) is an instrumental swallowing assessment increasingly used by speech pathologists (SPs) in Australia. The Speech Pathology Australia (SPA) position paper published in 2007 reflected the growing use of the technique by SPs in Australia at the time. Evidence supporting the use of FEES for diagnostic and treatment purposes has continued to strengthen, and now demonstrates that FEES can provide important clinical information to guide management of dysphagia. Many models of FEES service delivery remain strongly influenced by historical attitudes to the use of endoscopy. Some of these models are expensive and impose a significant cost on health care providers in terms of paid time, as well as having an impact on how patients can access the procedure. This paper provides a brief overview of the relevant literature regarding FEES, including a discussion of some of the points of difference between videofluoroscopic swallowing studies (VFSS) and FEES. The paper also discusses service delivery models and approaches to training. A well-considered approach to training is an integral part of developing a sustainable FEES service to ensure safe, effective, and equitable access to patients. Instrumental swallowing assessments Speech pathologists use both clinical (non-instrumental) and instrumental techniques to assess swallowing function (American Speech-Language Hearing Association [ASHA], 2000; Carnaby-Mann & Lenius, 2008); College of Audiologists Speech-Language Pathologists of Ontario [CASLPO], 2007. In many instances, an individual patient’s swallowing function is assessed using both clinical and instrumental assessments. Videofluoroscopic swallowing studies (VFSS) and fibreoptic endoscopic evaluation of

swallowing (FEES) are the most widely employed instrumental swallowing assessments used to evaluate oro-pharyngeal swallowing function. As instrumental swallowing assessments, both FEES and VFSS aim to achieve the same broad objectives. They can be used to discriminate between normal versus abnormal swallowing and where dysphagia is identified, to determine the level of function and impairment ([CASLPO], 2007 and [ASHA], 2000). Both FEES and VFSS enable judgements to be made about which textures, consistencies, volumes, rate, and methods of delivery maximise safety and efficiency of the swallow. Both examinations can also be used to evaluate the effectiveness of compensatory or rehabilitative interventions (Carnaby-Mann & Lenius, 2008; Leder & Murray, 2008). VFSS and FEES VFSS is the most widely used instrumental swallowing assessment. VFSS provides radiographic images of the upper aerodigestive tract, enabling observations to be made of the oral, pharyngeal, and upper oesophageal phases of swallowing, as well as the interplay between these various stages of swallowing (Martin-Harris & Jones, 2008). This view is generally regarded as providing the superior view of oral stage function (Langmore, 2001). It is also often the more appropriate examination when symptoms are vague, and an overview of swallowing function across the various phases is indicated (Langmore, 2001). The value of the visual images provided by VFSS depends on the clinical question that needs to be answered for a particular patient’s clinical management. There are also practical and logistical considerations that may limit access to VFSS for some patients. FEES is not only an alternative instrumental assessment to VFSS. It is an examination that can provide unique information about swallowing function that, for some patients, may be more clinically relevant. FEES involves passing the flexible portion of an endoscope (nasendoscope/rhinolaryngoscope) through the nose while connected to a camera to enable audio-visual images to be captured. In the oro-pharynx, where the scope is positioned for the most part of the examination, ideally, the base of tongue and laryngeal vestibule are in full view. The scope can be advanced inferiorly to enable the sub-glottic region to be visualised. Research has shown FEES to be a viable tool for identifying and characterising features of swallowing

Keywords fibreoptic endoscopic evaluation of swallowing (FEES) service delivery

models training

This article has been peer- reviewed

Michelle Cimoli (top) and Joanne Sweeney

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JCPSLP Volume 14, Number 1 2012

Journal of Clinical Practice in Speech-Language Pathology