Harmonization of Flexible Endoscopic Evaluation of Swallowing Practice: Pragmatic Implementation of Outcomes-Focused Procedures in the Acute Hospital Setting.

Flexible endoscopic evaluation of swallowing (FEES) has long been considered one of the gold standards for assessment of swallowing in both pediatric and adult populations (Hartnick et al. Ann Otol Rhinol Laryngol 109(11):996–999, 2000; Langmore. Dysphagia 32(1):27–38, 2017; Rao et al. J Appl Res 18:53–57, 2003). In both children and adults, FEES is used to evaluate the structure and function of the upper airway, secretion management, pharyngeal swallowing function, and effectiveness of strategies to improve the safety and efficiency of swallowing. In pediatric FEES, one must consider development, growth, and relative positions of the pharynx and larynx (Delaney and Arvedson. Dev Disabil Res Rev 14(2):105–117, 2008; Lieberman et al. Arch Oral Biol 46(2):117–128, 2001; Pohunek. Paediatr Respir Rev 5(1):2–8, 2004; Prakash and Johnny. J Pharm Bioallied Sci 7(Suppl 1):S55–S58, 2015). In addition, neurophysiologic maturation including primitive reflex integration, coordination of central pattern generator-mediated feeding/swallowing behaviors, and maturation of respiratory/swallow coordination must be well understood (Barlow. Curr Opin Otolaryngol Head Neck Surg 17(3):187–193, 2009). The purpose of this chapter is to describe the procedures and strategies unique to FEES in the pediatric population. Prioritization of exam goals, roles of team members, and strategies for obtaining an optimal exam are discussed. The parameters of the FEES exam are discussed from a pediatric perspective. Practical considerations for the pediatric FEES clinic and case studies highlighting FEES in various pediatric populations are presented.

BackgroundNeurogenic dysphagia is one of the most frequent and prognostically relevant neurological deficits in a variety of disorders, such as stroke, parkinsonism and advanced neuromuscular diseases. Flexible endoscopic evaluation of swallowing (FEES) is now probably the most frequently used tool for objective dysphagia assessment in Germany. It allows evaluation of the efficacy and safety of swallowing, determination of appropriate feeding strategies and assessment of the efficacy of different swallowing manoeuvres. The literature furthermore indicates that FEES is a safe and well-tolerated procedure. In spite of the huge demand for qualified dysphagia diagnostics in neurology, a systematic FEES education has not yet been established.ResultsThe structured training curriculum presented in this article aims to close this gap and intends to enforce a robust and qualified FEES service. As management of neurogenic dysphagia is not confined to neurologists, this educational programme is applicable to other clinicians and speech–language therapists with expertise in dysphagia as well.ConclusionThe systematic education in carrying out FEES across a variety of different professions proposed by this curriculum will help to spread this instrumental approach and to improve dysphagia management.

Purpose The purpose of this systematic review was to examine safety-related outcomes for patients with tracheostomy after flexible endoscopic evaluation of swallowing (FEES) to assess and manage their swallow, when compared to other non-instrumental swallow assessments such as clinical swallowing examination (CSE) and/or a modified Evans blue dye test (MEBDT). Method Three databases were searched for articles referring to safety-related outcome data for adults with a tracheostomy, who underwent FEES and CSE and/or MEBDT. Articles were screened using predefined inclusion/exclusion criteria. Result The search strategy identified 2097 articles; following abstract and full-text screening, seven were included for review. The summary of evidence found low to very low certainty that FEES was associated with improved outcomes across swallow safety, physiological outcomes, tracheostomy cannulation duration, functional outcomes, and detection of upper airway pathologies. Conclusion This systematic review demonstrated low to very low certainty evidence from seven heterogeneous studies with low sample sizes that incorporating FEES may be associated with improved safety-related outcomes. There is less evidence supporting the accuracy of other swallow assessments conducted at the point of care (i.e. CSE and MEBDT). Future research requires studies with larger sample sizes and routine reporting of safety-related outcomes with use of FEES.

The Dysphagia Outcome and Severity Scale is used both clinically and within dysphagia research, internationally. Although it was developed using videofluoroscopic swallowing studies, it is frequently used to rate Flexible Endoscopic Evaluations of Swallowing. The validity and reliability of DOSS-use with FEES, however, has not previously been evaluated. This study investigated the validity and rater reliability of clinicians using DOSS to rate FEES. Eleven Speech-Language Pathologists (SLPs) with varied dysphagia experience were recruited to review and DOSS-rate 17 soundless FEES (198 bolus swallows) recorded from 11 heterogenic dysphagic patients (2 cases with repeat FEES) and 4 healthy adults. The SLPs DOSS-ratings were compared against the initial comprehensive dysphagia evaluation (including patient diagnosis, interview, cranial nerve and complete FEES assessment) with Functional Oral Intake Scale (FOIS) and DOSS outcome measures. The SLPs were blinded to patient details and comprehensive dysphagia examination. Re-randomised rating of FEES cases occurred two weeks later (intra rater reliability). Criterion validity for DOSS-ratings (compared against comprehensive dysphagia evaluation with FOIS and DOSS) were strong–very strong (rs = 0.858 and 0.936 respectively; p < 0.001). Inter rater reliability demonstrated high agreement (α = 0.891), also intra rater reliability demonstrated almost perfect agreement (Kw = 0.945). This study’s results, with strong–very strong criterion validity and high rater reliability by SLPs, adds to the evidence for DOSS-use with FEES. Future validity research comparing DOSS with both FEES and VFSS simultaneously is recommended.

Background: During the Coronavirus Disease 2019 (COVID-19) pandemic, assessment of swallowing disorders by speech-language pathologists in the acute care setting was a challenge, resulting in limited reports on acute COVID-19 dysphagia. This study aimed to report on the characteristics of dysphagia as a direct consequence of acute COVID-19 infection. Methods: Study staff carried out a retrospective review, approved by the local ethics board, of patients who were admitted to an acute care urban hospital with a primary diagnosis of acute COVID-19 and received a flexible endoscopic evaluation of swallowing (FEES) during their acute phase of illness from March 2020 to May 20, 2022 (15 months). Data extraction included the Penetration Aspiration Scale (PAS) score for each bolus consistency, prolonged intubation, advanced age, laryngeal trauma, presence of secretions, and use of high-flow nasal cannula at the time of the FEES. Statistics were calculated according to variable and distribution type. Results: The study cohort consisted of 15 patients: 14 of 15 patients (93%) exhibited abnormal PAS scores (PAS 3-8) on at least 1 bolus on the FEES. A total of 66.6% (n= aspirated (PAS 6-8), but notably, 46.7% (n=7/15) silently aspirated (PAS 8). Most (n=10/15)50%) aspiration events occurred during the swallow, and top reasons for aspiration included laryngeal trauma (n =30%) and incoordination (n=30%). Conclusion: This study suggests that patients with acute COVID-19 are at risk for silent aspiration. Clinical implications of these findings suggest that patients with COVID-19 would benefit from formal instrumental swallowing assessment to prevent negative sequelae of dysphagia during acute illness. Cite this article as: Miglio E, Scott C, Chickakuragod A, et al. Characteristics of dysphagia in patients with COVID-19 in the acute care setting—a retrospective study. Balkan ORL-HNS 2025;2(2):33-39.

The use of narrow band imaging (NBI) during flexible endoscopic evaluation of swallowing (FEES) is recognised as an emerging technology to improve the contrast of the test fluid during endoscopic dysphagia evaluation. This study tested the hypothesis that the use of NBI in FEES would improve the detection of laryngeal penetration and aspiration in patients with unilateral vocal fold paralysis/paresis (UVFP), a typically difficult population in which to detect the presence of aspiration with FEES. Twenty-one consecutive outpatients with UVFP were evaluated with FEES using white light (WL) and NBI under 150 test conditions (75 WL & 75 NBI). Three speech pathologists, highly experienced in FEES using WL but novices to using NBI, rated laryngeal penetration and aspiration for green dyed thin fluid (5ml and 90ml) and mildly thick fluid (5ml) milk, and were compared to two raters more experienced in using NBI during FEES. Laryngeal penetration and aspiration were significantly higher for larger volumes (90ml) (p < 0.05). With NBI-naïve raters, there was a trend towards lower intra-rater and inter-rater reliability compared to WL on all bolus trials reaching significance on mildly thick fluid (p < 0.01). There was lower rater confidence when using NBI compared to WL in NBI-naïve raters to detect aspiration (p < 0.01). Sensitivity was lower regardless of NBI experience; 80.77-84.21% with WL compared to 46.15-50.00% with NBI. Findings indicate that the improved contrast of a dyed opaque milk trial under WL may negate the potential benefits of using NBI to increase the contrast of the test fluid and supports the use of an opaque test fluid such as milk. NBI may also not be as useful to clinicians with no experience with the altered light condition, and can result in lower sensitivity in even the experienced user.

Diminished pharyngeal constriction is a common biomechanical deficit associated with dysphagia and holds strong predictive value for aspiration. Pharyngeal squeeze manoeuvre (PSM) was previously validated for evaluating pharyngeal constriction on endoscopy. However, PSM is not routinely used in laryngology clinics or flexible endoscopic evaluation of swallowing (FEES) protocols worldwide. This study explored PSM in the acute care setting and its relationship with swallowing safety and efficiency, other swallowing biomechanical functions, and clinical outcomes. This prospective observational study consented 222 consecutive inpatients of mixed aetiology who were receiving FEES as part of their standard care. Established FEES protocols were performed including assessment of secretion accumulation, urge-to-clear ratings, laryngeal motor, and sensory functional tests, PSM, as well as aspiration, and residue during oral trials. Swallow frequency and cough peak flow were also collected as well as clinical outcomes at discharge. PSM was impaired in 46% of the patients. Accumulated secretions, penetration-aspiration, and post-swallow residue were frequent and correlated with abnormal PSM (p < 0.05). PSM was reliable and agreed with pharyngeal constriction ratio on videofluoroscopy in all 15 patients who had both assessments within 72 h. Abnormal PSM correlated with vocal cord immobility, reduced peak cough flow, and reduced swallow frequency (p < 0.05). Abnormal PSM predicted restricted diet on hospital discharge with an odds ratio of 10.38. PSM is a quick and simple addition to an endoscopic evaluation and has the potential to predict likelihood of impaired swallow safety and efficiency as well as clinical outcomes. 3 Laryngoscope, 133:3429-3435, 2023.

Demographic changes will raise the need for specialized care of older patients. Oropharyngeal dysphagia has recently been declared a geriatric syndrome reflecting its multifactorial background. Alongside multimorbidity, sarcopenia, frailty, and disability, swallowing disorders increase with advancing age, with prevalence rates reported to be as high as 44% in acute geriatric hospital settings and 80% in long-term care facilities. Hence, systematic screening of older patients to diagnose dysphagia and initiate treatment is of paramount importance to prevent bolus death, aspiration pneumonia, and malnutrition and improve quality of life. Several screening tools have been evaluated in emergency and stroke units. However, no published dysphagia screening tool has been validated in the hospitalized, older adult population using a gold standard in dysphagia diagnostics as a reference test. The validation of the proposed test is a first step. The Geriatric Bedside Swallowing Screen (GEBS) study aims to validate a new screening tool developed specifically for older inpatients against an instrumental swallowing evaluation, the flexible endoscopic evaluation of swallowing (FEES), which is considered a gold standard. Primary outcomes to be evaluated are sensitivity and specificity for the GEBS in the detection of dysphagia in a mixed older adult population. The presence of dysphagia will be defined by an instrumental swallowing evaluation (FEES), analyzed by the standardized penetration-aspiration scale. To validate the GEBS, a prospective cohort study will be carried out. Two institutions, an acute geriatric department and a long-term care facility, will aim to recruit a total of 100 patients aged ≥75 years. After giving their informed consent, patients will undergo the full screening protocol described in the GEBS as well as an evaluation of swallowing function using the FEES. Investigators will be blinded to the results of the respective other testing. The analysis of pseudonymized data sets will be done by a third investigator. Outcomes to be considered are sensitivity, specificity, diagnostic odds ratio, positive and negative likelihood quotient, and the reliability of the proposed dysphagia screening tool using the κ coefficient. Recruitment started in October 2022 and will end in April 2024. Data publication is planned for early 2025. If proven to be a valid screening tool for the early detection of dysphagia, further studies including different older adult populations as well as studies to determine the impact of systematic dysphagia screening on parameters, such as rates of aspiration pneumonia or nutritional status, should be planned. Effective screening of dysphagia will lead to earlier detection of patients with impaired swallowing. Those who fail the screening will be referred to speech language pathology for further diagnosis, thus optimizing care while streamlining personnel resources. ISCRTN Registry ISRCTN11581931; https://www.isrctn.com/ISRCTN11581931. DERR1-10.2196/46252.

To assess the effects of a typical otolaryngologic dose of 1 mL of 4% lidocaine on penetration aspiration scale scores and participant discomfort during flexible endoscopic evaluation of swallowing. A prospective pilot study. Twenty healthy participants consumed 12 swallows consisting of graduated volumes of milk, water, pudding, and cracker in anesthetized and nonanesthetized conditions. Each participant was randomly selected to begin with the anesthetized or nonanesthetized condition. Each participant returned within 7 days to repeat the study in the other condition. Digital recordings of their evaluations were scored via the penetration-aspiration scale in a blinded fashion. Participants recorded their discomfort and tolerance of each flexible endoscopic evaluation of swallowing. The anesthetized condition yielded significantly worse swallowing function (P = .001) than the nonanesthetized condition. The nonanesthetized condition yielded greater discomfort and pain during the procedure (P = .006, .018), greater pain during insertion and removal of the endoscope (P = .002, .003) and less overall tolerance (P = .016) than the anesthetized condition. A typical otolaryngologic anesthetic dose of 1 mL of 4% lidocaine during flexible endoscopic evaluation of swallowing predisposed healthy young adults to higher penetration aspiration scale scores (less safe swallowing) than the nonanesthetized condition; however, the anesthetic reduced discomfort and provided better overall tolerance. Future studies need to evaluate the effects of lower doses of lidocaine (0.2 and 0.5 mL) on swallowing function and comfort.

Although many hospitals universally screen their patients for functional mobility and activity impairment, there is no common method to do this for cognitive impairment. Establishing an interdisciplinary and standardized process to screen for cognitive impairment is essential for early identification of impairments, optimization of patients' function, and safe discharge planning. Previously, the reliability and validity of the Activity Measure for Post-Acute Care Applied Cognitive Inpatient Short Form "6-Clicks" (AM-PAC ACISF) were measured among occupational therapy practitioners and speech-language pathologists; however, its reliability among other team members, specifically nurses, is unknown. This study reports the interprofessional interrater reliability of the AM-PAC ACISF in the acute care hospital setting. To examine the nursing-therapist interrater reliability of the AM-PAC ACISF in the acute care hospital setting. A prospective study using a convenience sample. Acute care hospital. Fifty adult patients, six nurses, five occupational therapy practitioners, and one speech-language pathologist. Interrater reliability for the AM-PAC ACISF among therapists and nurses. Interrater reliability was good among nurses and therapists, with an intraclass correlation coefficient of .88 (95% confidence interval [.79, .93]) for the AM-PAC ACISF. Findings suggest that the AM-PAC ACISF is reliable for use among interdisciplinary teams, helps to establish a common language for early identification of cognitive impairment, and can be used for guiding clinical discussions around patient cognition in the acute care setting. Plain-Language Summary: Having an interdisciplinary and standardized process to screen patients early for cognitive impairment is essential for identifying impairments, optimizing patients' function, and facilitating safe discharge planning in the acute care setting. Early identification of cognitive impairment by the interdisciplinary team can also allow for timely occupational therapy and other rehabilitation service interventions. The findings of this study suggest that the Activity Measure for Post-Acute Care Applied Cognitive Inpatient Short Form "6-Clicks" (AM-PAC ACISF) can reliably be used by interdisciplinary teams, establishes a common language for early identification of cognitive impairment, and can be used for guiding clinical discussions around patient cognition in the acute care setting.

Dysphagia is independently associated with adverse outcomes in intensive care units (ICU). Early identification through dysphagia screening does not occur routinely, negatively impacting optimal patient management. This study aimed to validate the Swedish version of the Gugging Swallowing Screen-Intensive Care Unit (GUSS-IVA). This is a prospective multicentre study of 56 adult ICU patients with endotracheal intubation exceeding 48 h at three hospitals in Sweden. The GUSS-ICU was translated into Swedish (GUSS-IVA) and used to screen all prolonged intubated patients (>48 h) once extubated. The GUSS-IVA screen was conducted by ICU nursing staff and then compared with a gold standard Flexible Endoscopic Evaluation of Swallowing (FEES) within 2 h of the GUSS-IVA screen. Fifty-one of 56 patients underwent FEES (where assessors were blinded to the GUSS-IVA screen results). Sensitivity and specificity were calculated, as was the area under the receiver operating characteristic curves (AUC) with 95% confidence intervals (CI). For inter-rater reliability, within 2 h of the initial screen, 29/56 patients were GUSS-IVA screened a second time by a nursing staff blinded to the first GUSS-IVA results. Among the 56 patients, 38 (67.9%) were identified as dysphagic using the GUSS-IVA screen. With FEES, 42 of 51 patients (82.4%) were diagnosed with dysphagia; of these, 16 (31.4%) were classified as aspirating. Compared to FEES, GUSS-IVA showed high sensitivity and specificity values (81% and 89%, respectively) with an AUC of 0.85 (95% CI: 0.71-0.95) and a positive predictive value of 97%. High convergent validity was obtained for GUSS-IVA compared with the Dysphagia Outcome Severity Scale (ɸ = 0.57, p < .001) and the Functional Oral Intake Scale (ɸ = 0.52, p < .001) and moderate validity with the Penetration-Aspiration Scale (ɸ = 0.30, p = .033). The inter-rater reliability showed moderate agreement (Cohen's kappa κ = 0.501, p = .006). This study indicates that the Swedish GUSS-IVA is a valid and reliable screen to identify dysphagic ICU patients. Given the negative impact of dysphagia on short and long-term patient outcomes, the Swedish GUSS-IVA is recommended as an essential first step by nursing staff for early identification of dysphagia for further diagnostics and subsequent patient management.

The Penetration Aspiration Scale (PAS), although designed for videofluoroscopy, has been utilized with flexible endoscopic evaluation of swallowing (FEES) in both research and clinical practice. The purpose of this investigation was to determine inter- and intrarater reliability of the PAS with FEES as a function of clinician FEES experience and retest interval. Three groups of 3 clinicians (N=9) with varying FEES experience (beginning, intermediate, and advanced) assigned PAS scores to 35 swallows. Initial ratings were repeated following short-term (ie, 1 day) and long-term (ie, 1 week) retest intervals. Intraclass correlation coefficients were calculated to assess interrater reliability on the first rating for each group. The coefficients were .91, .82, and .89 for the beginning, intermediate, and advanced clinicians, respectively. Overall interrater reliability across all 9 clinicians, irrespective of experience, was .85. Intraclass correlation coefficients were also calculated to assess intrarater reliability. The intrarater reliability for short- and long-term ratings was .90, .94, and .96 and .96, .97, and .94 for the beginning, intermediate, and advanced clinicians, respectively. Overall intrarater reliability across all 9 clinicians and all 3 ratings was .94. Excellent inter- and intrarater reliability was evidenced with the application of the PAS for FEES regardless of clinician experience and retest interval.

Purpose While flexible endoscopic evaluation of swallowing (FEES) is a common clinical procedure used in the head and neck cancer (HNC) population, extant outcome measures for FEES such as bolus-level penetration-aspiration and residue scores are not well suited as global patient-level endpoint measures of dysphagia severity in cooperative group trials or clinical outcomes research. The Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) was initially developed and validated for use during videofluoroscopic evaluations as a way to grade safety, efficiency, and overall pharyngeal swallowing impairment. The purpose of this study was to adapt and validate DIGEST for use with FEES. Method A modified Delphi exercise was conducted for content validation, expert consensus, adaptation, and operationalization of DIGEST-FEES. Three blinded, expert raters then evaluated 100 de-identified post-HNC treatment FEES examinations. Intra- and interrater reliability were tested with quadratic weighted kappa. Criterion validity against the MD Anderson Dysphagia Inventory, Functional Oral Intake Scale, Secretion Severity Scale, and Yale Residue Rating Scale was assessed with Spearman correlation coefficients. Results Interrater reliability was almost perfect for overall DIGEST-FEES grade (κw = 0.83) and safety grade (κw = 0.86) and substantial for efficiency grade (κw = 0.74). Intrarater reliability was excellent for all raters (0.9-0.91). Overall DIGEST-FEES grade correlated with MD Anderson Dysphagia Inventory (r = -.43, p < .0001), Functional Oral Intake Scale (r = -.43, p < .0001), Secretion Severity Scale (r = .47, p < .0001), Yale Vallecular Residue (r = .73, p < .0001), and Yale Pyriform Sinus Residue (r = .65, p < .0001). Conclusion DIGEST-FEES is a valid and reliable scale to describe the severity of pharyngeal dysphagia in patients with HNC. Supplemental Material https://doi.org/10.23641/asha.14642787.

This study investigated rater confidence when rating airway invasion with the penetration-aspiration scale (PAS) on flexible endoscopic evaluations of swallowing (FEES), raters' accuracy against a referent-standard, inter-rater reliability, and potential associations between clinician confidence, experience, and accuracy. Thirty-one clinicians who use FEES in their daily practice were asked to judge airway invasion with the PAS and to rate their confidence that their score was correct (0-100) for 40 video clips, five in each of the 8 PAS categories. We found that raters were most confident in rating PAS 1, 7, and 8. The average confidence score across all videos was 76/100. Confidence did not have a significant relationship with accuracy against the referent-standard. Accuracy was highest for PAS 1 (92%), followed by PAS 8 (80%), PAS 7 (77%), and PAS 4 (72%). Accuracy was below 60% for PAS 2, 3, 5, and 6, the lowest being for PAS 3 (49%). Mean accuracy for all ratings, compared to referent-standard ratings, was highest for the intermediate group (71%), followed by expert (68%) and novice (65%). In general, we found that certain PAS scores tend to be rated more accurately, and that participating SLPs had varied confidence in PAS ratings on FEES. Potential reasons for these findings as well as suggested next steps are discussed.

This study investigated the reliability and validity (sensitivity and specificity) of cervical auscultation (CA) using both swallow and pre-post swallow-respiratory sounds, as compared with Flexible Endoscopic Evaluation of Swallowing (FEES). With 103 swallow-respiratory sequences from 23 heterogenic patients, these swallows sounds were rated by eight CA-trained Speech-Language Pathologists (SLPs) to investigate: (1) if the swallow was safe (primary outcome); (2) patient dysphagia status; (3) the influence of liquid viscosity on CA accuracy (secondary outcomes). Primary outcome data showed high CA sensitivity (85.4%), and specificity (80.3%) with all consistencies for the safe measurement, with CA predictive values of > 90% to accurately detect unsafe swallows. Intra-rater reliability was good (Kappa = 0.65), inter rater reliability moderate (Kappa = 0.58). Secondary outcome measures showed high sensitivity (80.1%) to identify if a patient was dysphagic, low specificity (22.9%), and moderate correlation (rs= 0.62) with FEES. A difference across bolus viscosities identified that CA sensitivities (90.1%) and specificities (> 84.7%) for thin liquids were greater than for thick liquids (71.0–77.4% sensitivities, 74.0–81.3% specificities). Results demonstrate high validity and moderate-good reliability of CA-trained SLPs to determine swallow safety when compared with FEES. Data support the use of CA as an adjunct to the clinical swallow examination. CA should include pre-post respiratory sounds and requires specific training. Clinical implications: The authors advocate for holistic dysphagia management including instrumental assessment and ongoing CSE/review + CA. Adding CA to the CSE/review does not replace instrumental assessment, nor should CA be used as a stand-alone tool.