Fiberoptic Endoscopic Evaluation of Swallowing (FEES) Guidelines

Procedure Overview

The American College of Chest Physicians recommends FEES as a bedside or clinic-based instrumental swallowing assessment that involves transnasal passage of a flexible nasopharyngoscope to directly visualize the pharynx and larynx before and after swallowing, providing real-time anatomical and functional information in patients with dysphagia 1, 2
FEES can be performed at the bedside or in a clinic area, making it highly portable and practical for assessing swallowing disorders in various patient populations 1, 3

FEES provides comprehensive assessment of multiple swallowing parameters, including structural assessment of laryngeal morphology and motility, velo-pharyngeal closure competence, and functional deficits such as impaired chewing and tongue muscle deficit, which directly impact aspiration risk and patient safety in patients with oropharyngeal dysphagia 4, 5
FEES enables detection of safety indicators, including pharyngeal residues and secretion pooling, allowing for timely intervention to prevent aspiration and other complications in high-risk patients 4, 5

The American College of Chest Physicians recommends that patients with dysphagia should undergo either videofluoroscopic swallow evaluation (VSE) or FEES to identify appropriate treatment, with a Grade B recommendation, highlighting the importance of instrumental assessment in guiding treatment decisions 1, 2, 6
FEES is considered an efficient method for assessment of oropharyngeal dysphagia, particularly valuable for detecting silent aspiration, which occurs in up to 55% of patients who aspirate, and enabling implementation of appropriate compensatory techniques and identification of dysphagia rehabilitation plans 4, 5

The American Geriatrics Society recommends instrumental assessment, including FEES, when signs of dysphagia are present at clinical evaluation, silent aspiration is suspected, or the clinical scenario is unclear, emphasizing the need for comprehensive assessment in older adults with swallowing disorders 3
Bedside clinical evaluations alone are insufficient to determine treatment interventions for dysphagia, highlighting the importance of instrumental assessment, such as FEES, in guiding treatment decisions 3

FEES provides direct visualization of anatomy and physiology during deglutition, unlike clinical swallow evaluations which rely on subjective judgments, allowing for more accurate assessment of swallowing function and aspiration risk 1, 2
Unlike videofluoroscopy, FEES does not involve radiation exposure and can be performed at bedside, making it a safer and more convenient option for patients with swallowing disorders 3

FEES cannot visualize the actual moment of swallowing due to "white-out" when the pharynx contracts, unlike videofluoroscopy which captures the entire swallow sequence, highlighting the importance of combining FEES with other assessment tools to ensure comprehensive evaluation 1, 2
The procedure requires adequate patient cooperation and cannot be performed on patients with lethargy, reduced level of consciousness, or inability to manage oral secretions, emphasizing the need for careful patient selection and preparation 7

The stroke rehabilitation guidelines recommend fiberoptic endoscopic evaluation of swallowing (FEES) as the preferred alternative to a modified barium swallow for assessing dysphagia in patients who cannot undergo videofluoroscopic swallowing studies. This recommendation applies to individuals with dysphagia who are unable to be imaged with radiation‑based techniques. 8, 9
FEES should be used as the first‑line instrumental assessment when a modified barium swallow is unavailable or contraindicated, according to the same stroke rehabilitation guidelines. The guidance emphasizes FEES for bedside or clinic use in patients where radiology access is limited or radiation exposure is a concern. 8, 9

Case‑series evidence indicates that FEES and videofluoroscopic swallow studies each identify some aspirating patients that the other modality misses, and neither test has demonstrated clear superiority overall. This finding supports the use of either instrument based on clinical context rather than assuming one is universally better. 8