What is
FEES?

Fiberoptic Endoscopic Evaluation of Swallowing (FEES) is an instrumental assessment for dysphagia (swallowing disorders) performed by a licensed Speech‑Language Pathologist (SLP). A thin, flexible endoscope is passed transnasally to the oropharynx and hypopharynx, allowing real‑time, full‑color visualization of:

The pharynx (throat)
The larynx (voice box)
The upper esophageal sphincter (entrance to the esophagus)

During the exam, the patient ingests a variety of foods and liquids. The SLP evaluates:

Swallow safety and efficiency
Aspiration (including silent aspiration)
Pharyngeal residue and bolus flow
Appropriate diet levels
Compensatory and therapeutic strategies

Is FEES a new technique?

No, FEES is not a new technique! Fiberoptic Endoscopic Evaluation of Swallowing (FEES) is well established and has been used in the field of dysphagia diagnostics since the 1980s. FEES is a sensitive, accurate, portable, and safe examination that gives clinically useful information relative to swallowing physiology and swallowing safety.

Why FEES Is Trusted

Established Methodology: First described by Langmore et al. in 1986 and validated in 1988, FEES has been in clinical use for over 35 years.
Portability: Conducted bedside, at the dining table, or in any care setting—ICU, long‑term care, outpatient clinic—in about 15 minutes.
Safety: No radiation or barium; minimal patient discomfort.
Repeatability: Can be performed as often as needed to monitor progress or fatigue effects.

FEES is also known by a few other names including: “video endoscopic evaluation of dysphagia” and “bedside endoscopic swallowing test." FEES generally falls within the scope of practice of a Speech-Language Pathologist.

More information and research regarding FEES can be found here.

When someone is having difficulty swallowing,
a quick and comprehensive diagnosis is critical.

The importance of instrumental imaging -

Properly diagnosing swallowing issues can be difficult. Video imaging is essential for accurate and comprehensive diagnosis/recommendations.

Imagine this: You fell and think you broke your leg. You'll need an x-ray to confirm that and provide recommendations for follow-up (brace, cast, surgery, etc.).

Swallowing imaging is like x-ray imaging in this example!

We need swallowing imaging to provide comprehensive assessment and recommendations for follow-up.

We can't diagnose what we can't see. Visualization of anatomical and pathophysiological deficits enables us to make appropriate recommendations. Once we obtain baseline imaging, we can use our clinical judgement to form a treatment plan.

Why can't we just downgrade to thickened liquids and be good to go?

Sure, we can downgrade, but, ultimately, a long-term downgrade is not the goal and is often not clinically indicated.

In fact, some swallowing exercises and strategies, such as thickened liquids, have been shown to actually cause harm to a patient and potentially cause a subsequent re-hospitalization if implemented for an unnecessary reason.

E's Mobile FEES knows first-hand the dilemma of residents being “stuck” on pureed foods and thickened liquids, losing weight, and/or suffering an aspiration pneumonia because they are too weak or otherwise medically compromised to travel out of the facility for a swallowing assessment. Mobile FEES provided on-site offers a solution to that problem.

WHY CHOOSE MOBILE FEES?

Bringing FEES to your facility eliminates transport barriers and delivers rapid, evidence‑based care:

Quick Turnaround: On‑site within 1–3 days of referral; comprehensive report returned in 24–48 hours.
Cost Savings: Up to 40–50% reduction in per‑patient assessment costs versus hospital‑based studies (MBSS/VFSS), plus no transport fees.
Clinical Impact:
- Early detection of silent aspiration and residue
- Immediate diet modifications and strategy training
- Staff education in secretion management
- Identification of reflux, fatigue, and other post‑swallow risks
- Prompt ENT referral when indicated

The evidence is clear.

Clinical Bedside Swallowing Evaluations rely on external signs (coughing, voice change) and have significant limitations:

Variable Accuracy: Sensitivity 42–92%, specificity 59–91% for aspiration detection.
Silent Aspiration Missed: Up to 50% of aspiration events show no overt signs.
High Error Rates: Some studies report up to 70% of bedside evaluations misidentify aspiration or recommend inappropriate diets.

Instrumental studies like FEES and MBSS/VFSS provide direct visualization of the swallow, yielding more accurate diagnoses, reducing unnecessary diet restrictions, and guiding targeted interventions—ultimately lowering the risk of aspiration pneumonia and rehospitalization.

THE BIG PICTURE:

While it's challenging to give a single, definitive "error rate" for Clinical Bedside Swallowing Evaluations, because accuracy can vary based on several factors (specific protocol used, patient population, clinician experience, etc.), research suggests that Bedside Evaluations have a significant margin of error, particularly in identifying aspiration:

Accuracy: Studies suggest that Bedside Evaluations have variable accuracy, with some reporting an accuracy of only 52% in detecting aspiration when compared to Fiberoptic Endoscopic Evaluation of Swallowing (FEES).

Sensitivity and Specificity: Sensitivity (the ability to correctly identify those with aspiration) can range from 42% to 92%, while specificity (the ability to correctly identify those without aspiration) can range from 59% to 91%.

Detecting Silent Aspiration: Bedside Evaluations are particularly poor at detecting silent aspiration, which occurs without overt signs like coughing or choking. About 50% of aspiration is silent, meaning that half of aspiration events might be missed at the bedside.

70% Error Rate: Some sources cite up to a 70% error rate for Bedside Evaluations, suggesting that diet recommendations might be too restrictive, not restrictive enough, or silent aspiration might be missed.

Implications of Inaccurate Assessments: Inaccurate Bedside Evaluations can lead to inappropriate diet recommendations (e.g., unnecessary thickened liquids or tube feeding), missed aspiration, and potential complications like aspiration pneumonia, potentially increasing healthcare costs and impacting patient quality of life.

WHY DO ERROR RATES EXIST?

Limited Visibility: Speech-Language Pathologists (SLPs) cannot visualize the pharyngeal and esophageal phases of swallowing during a Bedside Evaluation. We need imaging to do that.

Reliance on Clinical Signs: Bedside Evaluations rely on observable clinical signs, such as coughing or voice changes, to identify aspiration. However, many patients, especially those with silent aspiration, don't exhibit these outward signs.

Subjectivity: Bedside Evaluations can be subjective, and inter-rater reliability (consistency between different evaluators) can be variable.

Clinical Bedside Swallowing Evaluations are a valuable initial tool for identifying potential dysphagia and aspiration risk, they have limitations that can lead to false positives and negatives.

Instrumental assessments, such as FEES and MBSS/VFSS, provide a more direct and objective view of the swallowing process, enabling more accurate diagnoses and treatment planning.

Studies show that using instrumental assessments can improve diagnostic accuracy and potentially decrease the incidence of aspiration pneumonia.

Additionally, research has consistently shown that FEES and MBSS/VFSS have a 97-100% inter-rater reliability with FEES being shown to be higher in specificity and severity in identifying penetration, aspiration, residue, and spillage.

Our Equipment:

At E's Mobile FEES, we use PatCom Medical’s Portable FEES System—an industry‑leading platform designed for flexibility and high‑quality imaging in any care environment. Its software suite allows frame‑by‑frame video review, ensuring the most accurate diagnostics and treatment planning.

Learn more about PatCom's Portable FEES System.

Mobile FEES from E’s Mobile FEES combines the gold‑standard accuracy of endoscopic swallowing evaluation with the convenience, safety, and cost‑effectiveness your residents deserve. Contact us today to schedule an on‑site assessment or staff training.