FEES Flashcards
Exam 2
Between FEES and VFSS (MBSImP), which one is the “gold standard”?
Neither!
List the three components of the Langmore FEES protocol.
- Anatomy and Physiology Assessment
- Swallowing Assessment
- Intervention Implementation
What are some normal anatomical variations that may effect swallow performance?
Low aryepiglottic folds create shallow lateral channels
Arytenoids resting close to posterior pharyngeal wall may decrease post-cricoid space
Epiglottis resting on tongue obliterates valleculae
Epiglottis resting posteriorly may enlarge valleculae
Narrow hypopharyngeal space
Epiglotti come in all shapes and sizes
In normal swallowing, there is an overlap between what two stages?
Oral and pharyngeal
In a normal swallow, how long can solid material collect in the valleculae during the mastication phase?
Up to 10 seconds in normal adults
True or False?Liquids may reach the pyriform sinuses prior to swallow onset in normal, healthy adults.
True. Dwell time 1-2 seconds. Tends to be longer for smaller amounts.
PAS of 2 or “flash” penetration is considered disordered or normal?
Normal
True or False:
Silent aspiration can be seen in normal healthy adults.
True!
In FEES, what are the four salient findings?
Swallow Onset
Residue
Penetration
Aspiration
Describe “Swallow onset”
Where does the bolus fall prior to swallow onset/initiation? Pyriform sinus? vallecula? PPW?
What is residue?
Bolus remains in hypopharyngeal cavities after the swallow. More than a coating; enough substance for remains to flow.
What is penetration?
Bolus material enters the laryngeal vestibule, over the rim of the larynx
What is aspiration?
Bolus material passes below the true vocal folds.
Where can residue occur?
Almost anywhere along the path! Most commonly: valleculae, pyriform sinus, and posterior pharyngeal wall.
If you observe vallecular residue, what could be 2 possible reasons?
Insufficient tongue base retraction/propulsion
Insufficient hyolaryngeal elevation reducing epiglottic inversion
If you observe residue in the pyriform sinusus, what could be 2 reasons?
Reduced hyolaryngeal elevation
Insufficient UES opening
What is the most important question when it comes to penetration/aspiration?
WHEN it happens.
What are some reasons (3) why penetration or aspiration might occur?
Reduced oral control/BOT retraction
Mistimed or reduced hyolaryngeal elevation, laryngeal vestibule closure & sealing
Inability to clear residue
Can you see the esophageal phase in the FEES?
Not technically. But we can see symptoms that may cue us to refer them for more testing, such as backflow causing after-swallow aspiration.
If you observe backflow or bubbling up from the UES, what are some (2) reasons this could be happening?
Air in esophagus
Retrograde movement of material in the esophagus
What are some structural problems to look for?
Incomplete closure of one or both TVCs/Inadequate airway protection.
Narrowed pharyngeal lumen.
What are some reasons why we might observe incomplete closure of one or both TVCs/inadequate airway protection? What could be an underlying cause of this?
Impaired neural signal to laryngeal muscles
Damage to tissue causing immobility (scarring)
Underlying Cause: Neurological event CVA Trauma Surgery Neoplasm
What are some reasons we might observe a narrowed pharyngeal lumen?
What could be an underlying cause of this?
Structural blockage
Bulky tissue
Underlying Cause:
Osteophyte
Congenital defect
Large body habitus
What “other information” are we looking for during a FEES?
respiration capabilities
What are we looking for in respiration abilities with the FEES?
Subtle adduction and abduction mirrors inspiration and expiration.
During rest breathing only the vocal folds and arytenoids should move
Swallowing usually occurs at the beginning of exhalation
Respiratory muscle fatigue associated with swallowing disorders
FEES allows observation of breathing/swallowing patterns
What does FEES Stand for?
Fiberoptic
Endoscopic
Evaluation of
Swallowing
What is a videoflouroscopic swallow study? Is it the same as FEES?
AKA: Modified barium swallow
So….no, it’s different.
When was the first publication of FEES?
1988
What are some aspects, per Dr. Langmore, that FEES offers (that VFSS doesn’t)?
Visualization of secretions
Direct view of surface anatomy,
Mucosal abnormalities (edema, erythema)
Observation of effects of altered anatomy on bolus flow and airway protection
Visualization of glottic closure
Clear observation of the bolus path and location of the bolus within the hypopharynx
What are some aspects, per Dr. Langmore, that VFSS offers (that FEES doesn’t)?
Visualization bolus during the height of the swallow
Analysis of both oral and esophageal phase
Observation of completeness of BOT retraction, UES opening, and extent of aspiration
View of submucosal changes (osteophytes, metal plates)
What does ASHA say about Fiberoptic endoscopy and SLPs?
That it is an imaging procedure that may be utilized by SLPs to evaluate swallowing function, as a therapeutic aid & biofeedback tool during swallow treatment.
Assessment & Management of Dysphagia falls within the scope of SLPs.
Is there a FEES certification?
No, except in TN. According to ASHA Code of Ethics: “Individuals shall engage in the provision of the professions that are within the scope of their competence, considering their level of education, training, and experience.”
So, know your stuff.
What are the four main components of the FEES equipment?
Nasoendoscope
Light Source
Camera with Endoscopic lens coupler
Video/Audio recording device
Do we sterilize or disinfect a FEES endoscope?
No, we disinfect
What is sterilization?
Elimination of ALL microorganisms & bacterial spores
Methods:
Autoclaving: high temperature & pressure
Not recommended for most endoscopes. May destroy adhesives used to manufacture scopes causing leaking and scope fogging.
Why don’t we sterilize the nasoendoscope?
Our nose and mouth are no sterile. Only sterile equipment for surgery.
What is disinfection?
Not complete elimination.
Scope is immersed in a solution for a specified soaking period.
List the steps in the commonly used disinfecting procedure.
Pre-cleaning Rinse Leak Testing High Level Disinfection Rinse Drying Storage
What is the first action of a swallow onset?
Movement of arytenoids to the mid line (VF adduction)
How is swallow initiation seen in flouroscopy?
Hyoid bone/laryngeal elevation.
What does the whiteout indicate?
Epiglottic inversion.
What is pharyngeal shortening?
When the lateral pharyngeal walls medialize and there is sequential contraction of pharyngeal constrictor muscles (stripping)
UES opening is tied with…
hyolaryngeal elevation
Is the completeness of UES opening better seen with VFSS or FEES?
VFSS
How does the UES open?
As larynx lifts up and forward, the UES is traction open (along with cricopharyngeal relaxation) allowing the bolus to pass into the esophagus
When passing the scope, how should you start?
Insert the endoscope slightly into each naris and assess the anatomy
Determine which side has the clearest opening or ask patient if they breathe better through one side.
Remove any debris by having patient blow nose
How do we assess VP competence?
have them say “donut”
Both nasal and oral sounds to stimulate VP closure.
What kind of abnormalities are we looking for?
Bumps, discoloration, secretions, asymmetry, etc.
Describe the “Pre-swallow Position”
Camera is above the epiglottis, with a view of the base of the tongue and the entire hypopharynx & larynx
Describe the “Post-Swallow Position”
Descend into larynx vestibule.
View vocal folds and subglottic region.
Quickly retract to pre-swallow position.
What does “whiteout” refer to?
Bright flash of white light reflected off the tissue surface back into scope
Where are the two possible locations we can experience whiteout?
High position: velum can trap end of scope against the posterior wall during elevation
Pre-Swallow Position: hyolaryngeal elevation with epiglottis retroflex may obliterate view momentarily
List some complications with using the endoscope.
Sneezing (uncommon)
Epistaxis (uncommon)
Laryngospasm (rare)
Vasovagal response (extremely rare)
List some advantages for the FEES.
Can be administered at bedside with most pts, including bariatric in natural head postures repeatedly without anesthesia for prolonged periods (fatigue during meals) Allows additional assessment of larynx & its functions Realistic estimates of stasis and secretions Visualize bolus flow directions May demonstrate effects of compensatory approaches maneuvers Staff SLP actively participates Uses real food/consistencies Inexpensive procedure Higher reimbursement rate ICU and isolation patients Biofeedback
List some advantages of the MBSS.
Visualizes oral, pharyngeal & cervical esophageal structures
Visualizes whole oropharyngeal swallow event
Can provide special measures (biomechanical,temporal)
May demonstrate effects of
compensatory approaches
maneuvers
Can be administered to most patients
List some disadvantages of the FEES.
Does not visualize oral cavity Does not visualize the moment of swallow (whiteout) Potential for Mild discomfort Gagging Nose bleeds (epitaxis) Laryngospasm or vasovagal response Difficult with combative pts Nasal/pharyngeal debris with heavy O2 users
List some disadvantages of the MBSS.
Uses radiation with limited exposure time
Mostly administered in a radiological suite
Uses barium sulfate mixed with food
Alters natural consistency
Unnatural head positioning
Requires radiologist or technician
Referring SLP not always active participant
Expensive
Unable to view secretions
Transportation to Radiology
