Instrumental Swallowing Assessments: VFSS vs FEES

Instrumental swallowing assessments are the gold standard when assessing dysphagia, aspiration, and abnormal swallowing anatomy and physiology in your speech therapy patients.

In this article, you’ll learn:

  • Who needs an instrumental swallowing assessment (and who doesn’t)
  • The difference between VFSS and FEES
  • How to overcome common barriers to getting an instrumental

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What Is An Instrumental Swallowing Assessment?

Instrumental swallowing assessments are evidence-based procedures for examining swallowing anatomy and function.

They’re often recommended if oropharyngeal dysphagia is suspected during a clinical swallow evaluation.

Instrumentals allow clinicians to watch a patient swallow—from inside their bodies and in real time. This allows you to see if laryngeal penetration, aspiration, and/or abnormal swallowing anatomy and physiology are present.

Plus, you can test swallowing treatments and compensatory strategies to see which actually result in a safer swallow for each patient (ASHA, n.d.)

Goals of Instrumental Assessments

An instrumental can help you assess:

  • Anatomy. Assess oral, laryngeal, pharyngeal, and upper esophageal anatomy and their impact on the swallow, including dysphagia
  • Bolus Movement. See the movement and timing of the bolus
  • Patient Awareness. How they respond to abnormalities when swallowing
  • Secretions. Look for secretions (and the patient’s ability to sense and clear them)
  • Cause. Assess the reason for any laryngeal penetration and/or aspiration
  • Treatment Options. Test treatment and compensatory strategies (ASHA, n.d.)

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What Are The Types of Instrumental Assessments?

The best known instrumental swallowing assessments are the modified barium swallow study also known as a videofluoroscopic swallowing study (VFSS) and the fiberoptic endoscopic evaluation of swallowing (FEES). 

VFSS vs FEES?

About The VFSS

The VFSS uses an X-ray to assess the oral preparatory, oral transit, and esophageal phases of the swallow in real time (Logemann, 1986; ASHA-3, n.d.) 

During the procedure, a patient consumes several food and liquid consistencies that are mixed with barium or another contrast material. This substance allows the X-ray to track boluses during a swallow.

VFSS can identify when, why, and how laryngeal penetration and/or aspiration occurs. It can also determine which swallowing treatment and compensatory strategies are effective.

It’s usually performed in a hospital’s radiology suite by a speech-language pathologist and radiologist.

Patients need to be able to sit upright and travel to the radiology suite to get this procedure. The VFSS is contraindicated for patients without a swallow responses or with a fistula (ASHA-3, n.d.)

About The FEES

The FEES is a procedure that passes a flexible tube through the nose. The tube has a light and camera to watch swallows in real time. It can be performed by an SLP, a physician, or both (Langmore et al., 1988).

The FEES can show how safe a patient is with oral intake and which swallowing strategies and therapies are effective. You can also see the vocal cords and how well secretions are managed (ASHA-2, n.d.)

With this option, there’s no radiation exposure and, since it’s portable, it can be used in any setting, including at bedside. It’s also significantly cheaper than the VFSS.

However, the FEES can’t visualize the oral or esophageal phases of swallowing (ASHA-2, n.d.) It can also be more difficult to view than the VFSS, given the camera’s movements and the potential of residue getting on the camera.

The FEES is contraindicated for patients with severe movement disorders or those with trauma to or obstruction of their nasal passage (ASHA-2, n.d.)

VFSS & FEES Training

Being considered competent in either the VFSS or FEES is largely facility-specific and state-specific.

Many facilities have their own competency requirements. This often include a certain number of supervised scope passes or videofluoroscopic swallowing studies.

A well-regarded VFSS training is the Modified Barium Swallow Impairment Profile: MBSImP™. The MBSImP is a standardized, evidence-based protocol for interpreting VFSS study results.

Two well-regarded FEES trainings are the Langmore FEES and FEES courses by Carolina Speech Pathology.

Who Needs An Instrumental Swallowing Assessment?

Here are potential reasons to refer a patient for an instrumental swallowing assessment:

  • Diagnose. To determine the severity and presence of dysphagia
  • Get more details. For patients who are newly diagnosed with dysphagia
  • Verify. For patients who showed inconsistent signs and symptoms of dysphagia during a clinical swallow evaluation
  • Treatment progress. Determine if progress has been made and what strategies to recommend next
  • Safety. To better understand how their swallowing is impacting their breathing, nutrition, or hydration
  • Anatomy & Physiology. To identify any disorders in swallowing anatomy and physiology
  • Test treatments. To trial and identify which swallowing strategies and treatments to recommend
  • Progressive diseases. They have a progressive disease that may cause or worsen dysphagia (ALS, Parkinson’s disease, multiple sclerosis, etc.)
  • High risk. They have a medical condition with a high risk for dysphagia (stroke)

Who Shouldn’t Get One?

Not everyone is appropriate for the VFSS or FEES.

Reasons not to recommend an instrument swallowing assessment include:

  • The patient isn’t medically stable enough or can’t physically tolerate the procedure
  • The results of the procedure won’t change the dysphagia treatment plan or management
  • The patient has a cognitive-communication deficit that impacts their ability to promptly and accurately follow directions
  • The patient has a decreased level of alertness that impacts their ability to promptly and accurately follow directions

Common Barriers to Getting An Instrumental Assessment

Common barriers to getting your patient an instrumental swallowing assessment include:

  • Patients living in a rural location
  • Resistance from physicians
  • Lack of staffing to complete procedures in a timely manner, despite availability
  • Lack of funding, including insurance coverage
  • Cost-saving incentives at medical facilities 
  • Resistance from patients, despite education about the purpose and benefits of exam and recommendations

While most of these factors are outside of your control, there are things you can do to increase your patient’s chances of getting the assessment.

You can educate medical staff about the benefits of instrumentals, including cost savings and health outcomes. You can also discuss the inherent limitations of bedside swallowing evaluations and how instrumentals can help.

Read The Case for Instrumental Assessments and Build A Case for Instrumental Assessments in Long-Term Care for helpful statistics and tips when advocating for instrumental assessments.

See The Dysphagia Pack for illustrated handouts describing instrumental assessments.

You can also try to speed up scheduling by checking with multiple local providers of instrumental assessments.

Or referring out to medical social work for help with access, including funding and community resources.

Speech Therapy Materials

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References

Adult Speech Therapy

Chung Hwa Brewer is an SLP and instructor at Western Washington University’s Communication Science Disorders program. Miwa Aparo is a researcher, editor, and occupational therapist. Alisha Kleindel is a clinician with 15 years of full-time speech therapy working experience. More about us →