INTERPRETASION OF FEES

Literatur Reading
Tita Puspitasari

Supervisor : dr. Bambang Purwanto, SpTHT-KL (K)

DEPT OF OTORHINOLARYNGOLOGY – HNS

SCHOOL OF MEDICINE PADJADJARAN UNIVERSITY
BANDUNG
2019
 INTRODUCTION
• FEES : Susan Langmore 1988. Direct visualization of the pharynx

and larynx immediately before and after a swallow.

• The equipment required to perform FEES includes a flexible

endoscope, viewing monitor, recording equipment and food testing

materials.

• Food : Water, thin liquid, puree, rice porridge, havermouth, and

biscuits. Colored green or blue for better visualization.

Maggie A. Kuhn Peter C. Belaftky: Functional Assesment of Swallowing. Bailey’s Otolaryngology Head and Neck Surgery.
Fifth edition. 2015. Volume 1 :825-836
Advantages VS Disadvantages
• Advantages: No radioactive, portable, not requiring a special room,

the results can be immediately known, inexpensive, well tolerated,

easy to do, can be done in a short time, not irritating, using ordinary
food and can be repeated as often as possible if needed.

• Disadvantages : Blind spot, cannot evaluate the cricopharynx and

esophagus.
Compare with Other Examinations
• Cannot perform bolus evaluation of the oral cavity, the level of

pharyngeal constriction, opening of the sphincter esophagus and

elevation of the hyoid / larynx when swallowing.

• Compared with FEESST, FEES is only examining the motor

components of the process of swallowing and assessing sensory

components indirectly.
Contra Indication & Complication FEES
• No absolute contraindications to do.

• Consider : Disorders of hemostasis, ↓consciousness, unstable vital

signs.

• Complications : Uncomfortable, feeling clogged, vomiting, syncope,

epistaxis anterior and posterior to laryngospasm.

• Langmore : 6.000 FEES examinations : 2 laryngospasm (0.03%), 4

vasofagal episodes (0.06%) and 20 epistaxis (0.3%).

Preswallowing Assessment
• The patient seated upright in a position appropriate for eating.

• Assessing oromotor function.

• Movement and strength of the tongue, labial, cheek, mole palate.

• Stick the tongue forward and move left and right.

• Inflates the cheek when the mouth is closed.

• Asking the patient to mention the letter AAA,see the movement of the

uvula and the mole palate to the anteroposterior.

• Endoscope inserted through the nasal cavity.

• Asses velopharyngeal competence → swallow without food.

• Endoscope into the hypopharynx, to visualize the structure under the

mole palate : Base of the tongue, valeculae, piriformis sinuses,

posterior pharyngeal walls, post cricoid.

• Endoscope epiglotis, structure of the larynx is examined plica vocalis

movement during phonation and inspiration, accumulated saliva

(standing secretion), salivary penetration/aspiration, cough reflexes.
 The "home position
endoscop” in the pharynx
just above the tip epiglottis

Maggie A. Kuhn Peter C. Belaftky: Functional Assesment of Swallowing. Bailey’s Otolaryngology Head and Neck Surgery.
Fifth edition. 2015. Volume 1 :825-836
 • Breath hold maneuver : Ability to close the supraglottis.

• Pharyngeal muscular : Pharyngeal Squeeze Maneuver/PSM :

Voluntary, forceful, high-pitched “eee” assessing the motion lateral

hypopharyngeal walls and narrowing pyriform sinuses.

Maggie A. Kuhn Peter C. Belaftky: Functional Assesment of Swallowing. Bailey’s Otolaryngology Head and Neck Surgery.
Fifth edition. 2015. Volume 1 :825-836
 PSM

PSM. A:. The pharynx is relaxed at rest. B: An Intact PSM. The patient says a
forceful “eee” and the lateral hypopharyngeal walls contract and obllterate the
pyriform sinuses (arrows).
Maggie A. Kuhn Peter C. Belaftky: Functional Assesment of Swallowing. Bailey’s Otolaryngology Head and Neck Surgery.
Fifth edition. 2015. Volume 1 :825-836
Aspiration : Passage of swallowed material below the vocal folds

SE. Langmore, et all. Predictors of Aspiration Pneumonia: How Important Is Dysphagia. 2001
 Penetration : Bolus material touch interior
walls of the larynx, approach true vocal cord

SE. Langmore, et all. Predictors of Aspiration Pneumonia: How Important Is Dysphagia. 2001
Premature spilling :
During preparatory or oral swallow stage
Prior to onset of pharyngeal swallow

SE. Langmore, et all. Predictors of Aspiration Pneumonia: How Important Is Dysphagia. 2001
Residue : Bolus left in hypopharyngeal cavities
Location : Vallecula, pyriform sinuses, pharyngeal wall (right, left,
posterior), post cricoid
Swallowing Assessment
• Starting by giving 1 spoon of puree, hold it in the mouth 10 seconds →

premature oral leakage or pre swallowing aspiration.

• Then swallow, less than 1 second (white spot / blind spot) due to

contraction velopharynx and pharyngeal elevation.

• The assessment just before and after this moment.

• Note : Food lateralization, penetration, aspiration, residues in

valeculae, piriformis sinuses, base of the tongue, and postricoid,

cough reflex.
• Residue : Repeated swallowing, effective cleaning.

• Aspiration (-), followed by rice porridge, stopped if aspiration.

• If there is no aspiration, carried out with 4 other food consistencies.

• Puree,rice porridge, havermout, thin liquid, water, biscuit

• Changes in head position and techniques, help the process of

swallowing are carried out during examination. FEES.

 Interpretation
Aspiration before the swallow 25% = oral and pharyngeal dysfunction

During the swallow 10% = neurologic disorder + sensory deficit

After swallow 65% = lingual/pharyngeal weakness/outlet obstruction

through the UES.

Postswallow regurgitation out of the esophagus into the pharynx (

esophagopharyngeal reflux) = rising tide sign“, presence of a zenker
diverticulum/profound esophageal dysmotility.

Maggie A. Kuhn Peter C. Belaftky: Functional Assesment of Swallowing. Bailey’s Otolaryngology Head and Neck Surgery.
Fifth edition. 2015. Volume 1 :825-836
Penetration Aspiration Scale
Theurapeutic Assessment
Compensatory Treatment Procedures

• Redirect the bolus flow through the oral cavity and pharynx.
• Eliminate aspiration, not alter the swallow physiology.
Postures
Sensory Enhancement Techniques
Modifying Bolus Volume and Speed of Feeding
Bolus Consistency (Diet) Changes
Intraoral Prosthetics

Shaum s. Sridharan, Cathy L. Lazarus, Milan R. Amin : Non Surgical Manangement of Swallowing Disorders. Bailey’s
Otolaryngology Head and Neck Surgery. Fifth edition. 2015. Volume 1 :838-847
Postures :
• Chin Tuck

• Head Tilt Posture

• Head Back Posture

• Head Rotation Posture

• Side-Lying Posture
Chin tuck
Head rotation

Head tilt Head back

Side lying
Direct Therapy Procedures
• Change the swallow physiology by altering specific

components of swallowing.

Range Of Motion, Resistance, and Control Exercises

Sensory-motor Integration Procedures

Maneuvers

Shaum s. Sridharan, Cathy L. Lazarus, Milan R. Amin : Non Surgical Manangement of Swallowing Disorders. Bailey’s
Otolaryngology Head and Neck Surgery. 2015. Fifth edition. Volume 1 :838-847.
Maneuvers

Shaum s. Sridharan, Cathy L. Lazarus, Milan R. Amin : Non Surgical Manangement of Swallowing Disorders. Bailey’s
Otolaryngology Head and Neck Surgery. 2015. Fifth edition. Volume 1 :838-847.
Maneuvers
• Supraglottic : The patient is asked to swallow food while holding his
breath and coughing after swallowing before inspiration. To close the
vocal fold and clean the residue.
• Super-supraglottic : Holding breath longer and deeper. Increase the
closure plica vocalis/help close the posterior vocal fold.
• Effortful swallow : Swallow while pressing the bolus firmly with the
muscle strength of the base of the tongue and pharynx.
• Mendelsohn's: Several swallowing movements while feeling the thyroid
protrusion raised, hold back

Shaum s. Sridharan, Cathy L. Lazarus, Milan R. Amin : Non Surgical Manangement of Swallowing Disorders. Bailey’s
Otolaryngology Head and Neck Surgery. 2015. Fifth edition. Volume 1 :838-847.
Flexible Endoscopic Evaluation Of Swallowing
With Sensory Testing (FEESST)

• Directly evaluates LP sensation by assessing the ability of a tactile

stimulus to elicit the laryngeal adductor reflex (LAR).

• Tip of the flexible endoscope or formally quantified with a LP air-pulse

stimulator → mucosa aryepiglottic fold.

Maggie A. Kuhn Peter C. Belaftky: Functional Assesment of Swallowing. Bailey’s Otolaryngology Head and Neck Surgery.
Fifth edition. 2015. Volume 1 :825-836
 Interpretation
• Intact LAR but absent PSM → first administered water

• Absent LAR but an intact PSM → puree.

• Absent LAR and PSM →small ice chip.

• Suspected aspiration of a bolus requires repetition of the same

volume and viscosity to confirm.

• Passes the water and puree→solids or pills.

Maggie A. Kuhn Peter C. Belaftky: Functional Assesment of Swallowing. Bailey’s Otolaryngology Head and Neck Surgery.
Fifth edition. 2015. Volume 1 :825-836
 Conclusion
FEES : Susan Langmore 1988. Direct visualization of the pharynx and
larynx immediately before and after a swallow.
The equipment : flexible endoscope, viewing monitor, recording
equipment and food testing materials colored green or blue.
No absolute contraindications to do.
Pre swallow assesment : Movement and strength of the tongue, labial,
cheek, mole palate
Swallow assesment : Aspiration, penetration, residue, spillage
Theurapeutic : Postures, maneuver