JCPSLP Vol 14 No 1 2012

better inform treatment and management of dysphagia. This may be a relevant consideration in smaller sized health services without an on-site radiology department. FEES has the potential to improve patient access to instrumental assessment. Neither FEES nor VFSS can be considered to be an objective swallowing assessment, nor to be a gold standard . Both VFSS and FEES rely on the clinician observing the procedure to make subjective judgement about the visual images obtained. These visual observations are vulnerable to various influences, human factors, errors, and biases. Training in the use of instrumental swallowing assessments improves clinicians’ ability to use these tools, and can improve the reliability of how observers identify anatomical landmarks and evaluate the function of physiological events associated with swallowing (Logemann, Lazarus, Keeley, Sanchez, & Rademaker, 2000; Wooi, Scott & Perry, 2001; Warnecke et al., 2009b). There is a growing appreciation and acknowledgement of the complementary information that VFSS and FEES provide, and where the findings from both examinations are integrated, speech pathologists are equipped to provide a responsive and effective plan for treating and managing dysphagia (Rugiu, 2007). Models of service delivery A FEES procedure can be considered as having three components: • technical – insertion and operation of the endoscope; • procedural – direction of the procedure including providing instruction to the patient and decision-making regarding textures, volumes, compensatory and rehabilitative techniques, and manoeuvres to be trialled; • interpretive – reviewing images on-line and via the recordings to evaluate swallowing function, and in turn use this information to make clinical recommendations to optimise swallowing safety and efficiency. Figure 5 shows a speech pathologist performing FEES. SPs with the appropriate competencies can be responsible for performing all components of the procedure (SPA, 2003). However, FEES is considered to be an advanced practice role (SPA, 2003). The competencies required to conduct FEES are not currently addressed in speech pathology undergraduate (entry-level) training.

In some instances, FEES may provide better visualisation of aspiration or penetration. Figure 4 depicts how FEES is able to identify penetration, where a lateral VFSS image may not have permitted such vision (the pooling in the pyriform fossae would obscure the contrast in the laryngeal vestibule). VFSS, however, is the most suitable examination when the proportion of a bolus that is aspirated needs to be quantified (Langmore, 2001). Figure 3. Lateral radiograph (left) showing residue in the valleculae. Endoscopic view (right) showing residue in the valleculae

Residue in pyriform fossae

Milk that has entered the laryngeal vestibule, and remains above the level of the vocal folds

Figure 4. Endoscopic view showing milk residue in the left pyriform fossae and the left lateral channel. Milk can also be seen within the laryngeal vestibule, above the level of the vocal folds Practical and logistical differences There are also distinct practical and logistical differences between FEES and VFSS. For example, FEES doesn’t involve exposing the patient to radiation, and therefore, may be considered the most suitable examination when the purpose of the examination is to evaluate the effect of biofeedback on swallowing function (Denk & Kaider, 1997). Similarly, FEES can be conducted as an extended examination to enable observations regarding how fatigue might impact on swallowing function (Warnecke et al., 2008), repeated examinations for patients with progressive neurological conditions (Leder, 1998), or a conservative examination where perhaps swallow trials would be unsafe for the patient (Langmore, 2001). The portable nature of FEES also means that patients who may have otherwise been limited to clinical swallowing assessment as a result of the acute nature or fragility of their primary medical condition, or physical status including issues with positioning, are able to undergo instrumental assessment to

Figure 5. Michelle Cimoli, speech pathologist, performing FEES in an outpatient clinic at Austin Health A reasonable body of published research now demonstrates the safety of FEES when it is conducted by trained SPs (Aviv et al., 2000; Aviv, Murry, Zschommler,

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JCPSLP Volume 14, Number 1 2012

Journal of Clinical Practice in Speech-Language Pathology