Table 2 - Fiberoptic endoscopic evaluation of swallowing (FEES®) examination protocol (Susan E. Langmore, Ph.D., 2004)
From the following article
Endoscopic evaluation of oral and pharyngeal phases of swallowing
Susan E. Langmore
GI Motility online (2006)
doi:10.1038/gimo28
| Patient Name:------------------Date: -------------Examiner:------------ |
| I. Anatomic-physiologic assessment |
| A. Velopharyngeal closure |
| Task: Ask patient to say "ee," "ss," other oral sounds; alternate oral and nasal sounds ("duh-nuh") |
| Task: Dry swallow |
| Optional: Have patient swallow liquids. Look for nasal leakage. |
| B. Appearance of hypopharynx and larynx at rest: |
| scan around entire HP. Note any anatomic abnormalities that impact swallowing and any suspicious lesions requiring referral to specialist. |
| Optional: Ask patient to hold breath and blow out cheeks forcefully (opens pyriform sinuses). |
| C. Secretions and swallow frequency |
| Observe amount and location of secretions and frequency of dry swallows over a period of 2+ minutes. |
| Task: If no spontaneous swallowing noted, cue the patient to swallow. |
| Go to ice chip protocol if secretions in laryngeal vestibule or if no ability to swallow saliva. |
| D. Base of tongue and pharyngeal muscles |
| 1. Base of tongue: |
| Task: Ask patient to say "earl, ball, call" or other postvocalic "l" words |
| 2. Pharyngeal wall medialization |
| Task: Ask patient to screech/squeal; hold a high pitched, strained "ee" |
| (Task: see laryngeal elevation task below) |
| E. Laryngeal function |
| 1. Respiration |
| Observe larynx during rest breathing (respiratory rate; (adduction/abduction) |
| Tasks: Ask patient to sniff, pant, or alternate "ee" with light inhalation (abduction) |
| Phonation |
| Task: Ask patient to hold "ee" (glottic closure) |
| Task: Ask patient to repeat "hee-hee-hee" five to seven times (symmetry, precision) |
| Elevation |
| Ask patient to glide upward in pitch until strained; hold it (pharyngeal walls also recruited) |
| Airway protection |
| Task: Ask patient to hold breath lightly (true vocal folds) |
| Task: Ask patient to hold breath very tightly (ventricular folds; arytenoids) |
| Task: Ask patient to hold breath to the count of 7 |
| Optional: Cough, clear throat |
| F. Sensory testing |
| Note response to presence of scope |
| Optional: Lightly touch pharyngeal walls, epiglottis, aryepiglottic (AE) folds |
| Optional: Perform formal sensory testing with air pulse stimulator |
| Note: Additional information about sensation will be obtained in part II and formal testing can be deferred until the end of the examination. |
| II. Swallowing of food and liquid: All foods/liquids dyed green or blue with food coloring if needed to visualize. |
| Consistencies to try will vary depending on patient needs and problems observed. Suggested consistencies to try: |
 Ice chips: usually one-third to one-half teaspoon, dyed green |
| Thin liquids: milk, juice, formula. Milk or other light-colored thin liquid is recommended for visibility. Barium liquid is excellent to detect aspiration, but retract the scope to prevent gunking during the swallow. |
| Thick liquids: nectar or honey consistency; milkshakes |
| Puree |
| Semisolid food: mashed potato, banana, pasta |
| Soft solid food (requires some chewing): bread, soft cookie, casserole, meat loaf, cooked vegetables |
| Hard, chewy, crunchy food: meat, raw fruit, green salad |
| Mixed consistencies: soup with food bits, cereal with milk, apple |
| Amounts/bolus sizes |
| If measured bolus sizes are given, a rule of thumb that applies to many patients is to increase the bolus size with each presentation until penetration or aspiration is seen. When that occurs, repeat the same bolus size to determine if this pattern is consistent. If penetration/aspiration occurs again, do not continue with that bolus amount. The following progression of bolus volumes are suggested: |
| <5 cc if pt is medically fragile and/or pulmonary clearance is poor |
| 5 cc (1 teaspoon) |
| 10 cc |
| 15 cc (1 tablespoon) |
| 20 cc (heaping tablespoon, delivered) |
| Single swallow from cup or straw: monitored |
| Single swallow from cup or straw: self-presented |
| Free consecutive swallows: self-presented |
| Feed self food at own rate |
| The FEESR ice chip protocol |
| Part I: Emphasize anatomy, secretions, laryngeal competence, sensation |
| Note spontaneous swallows, cued swallow |
| Part II: Deliver ice chips |
| Note effect on swallowing, effect on secretions, presence of cough if aspirated. |
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