FEES versus
MBSS/VFSS

When you have the choice of endoscopy and fluoroscopy to evaluate swallowing, why choose FEES?

How does FEES compare to MBSS/VFSS?

First, what is MBSS/VFSS?

The Modified Barium Swallow Study (MBSS), also known as a video-fluoroscopic swallow study (VFSS), is a common, older procedure for the assessment of dysphagia. It is performed in the video-fluoroscopy (i.e. x-ray) suite at a hospital and involves a Radiologist, a Radiology Technologist, and a Speech-Language Pathologist (i.e. Speech Therapist or "SLP"). The patient must be seated in an upright position and fed barium coated food while being x-rayed. The MBSS/VFSS study is time limited in order to reduce radiation exposure. Due to this time limitation, it cannot account for the impact of fatigue on swallowing. Food and liquid consistencies are simulated through the use of liquid barium and barium mixed into foods.

Which one is the "gold standard" in diagnosing swallowing disorders?

This really comes down to what information is needed, where the patient is located, and if the patient can be transported. In some situations, BOTH FEES and MBSS/VFSS may be necessary to completely understand the complexity of the swallowing disorder. Current clinical research supports that both FEES and MBSS/VFSS are their own “gold-standards.”

Though both can be considered "gold-standards," FEES has repeatedly demonstrated a sensitivity equal to or greater than MBSS/VFSS in determining whether a patient is exhibiting penetration, aspiration, delay in swallowing initiation, and pharyngeal residue. Additionally, FEES provides visualizations of pharyngeal secretions (i.e. throat secretions) that cannot be detected during MBSS/VFSS.

Learn more about FEES and MBSS/VFSS research and articles HERE

Now, why choose FEES?
See some examples below:

Your patient has positioning limitations or doesn't tolerate leaving the facility or room (bedbound, Broda Chair, etc.):

FEES is completed at the patient's bedside, chair/wheelchair, dining room, lounge, or wherever they feel most comfortable. If the patient cannot sit upright, FEES is completed in the position that the patient will be in during eating.

There are no positioning limitations when conducting FEES.

Since FEES doesn't require transport and the patient can be in any comfortable position for testing, the patient is kept comfortable throughout the duration of the assessment, no matter the time length. FEES allows for a patient to eat and drink at their own pace, so their actual day-to-day eating and drinking is assessed.

Example patients include: Bariatric patients, bedbound patients, patients with wounds, patients who are ventilator dependent, patients who are easily fatigued, and patients with CP, MS, or MG

Your patient has severe pharyngeal dysphagia and you're concerned about aspiration during testing:

Aspiration of secretions or aspiration of enteral feeds are major predictors for possible development of aspiration pneumonia. FEES is a sensitive and conservative assessment that aids in the visualization of secretions, possible enteral feed backflow, and intake of ice chips because of its ability to visualize the throat and swallow in full color.

With FEES, there is no need to delay testing for patients who have severe to profound dysphagia. Critical information can be obtained at the bedside regarding specific swallowing impairments and anatomical integrity. This allows for appropriate therapy plans and recommendations to be established right away.

Example patients include: Patients who are feeding tube dependent, patients who are NPO, patients who are at risk for silent aspiration, patients who have progressive neurodegenerative conditions, and patients who have an increased risk for impaired cough reflex

Your patient has respiratory difficulties that impacts their swallow:

The prevalence of dysphagia in those with COPD and other pulmonary disorders is high. Research indicates that patients with COPD have a high tendency for aspiration and have reduced laryngeal sensation (i.e. throat sensation). One, or both, of these can lead aspiration and silent aspiration. Furthermore, patients with pulmonary deficits frequently cough outside of oral intake, making it difficult to determine if dysphagia is present and if it is impacting generalized swallowing safety.

FEES offers a direct view of the swallow and respiratory pattern as both the airway and pharyngeal swallow can be seen during the assessment. Disruptions in breath/swallow coordination, as well as the impact of shortness of breath, can be assessed during FEES.

Example patients include: Patients with COPD and other pulmonary deficits, patients with tracheostomy, patients who are ventilator dependent, and patients who may have reduced respiratory capacity or respiratory fatigue

Your patient would benefit from assessment with real foods and liquids, or they have specific food/liquid preferences:

The sensory properties of foods and liquids are well known to impact swallowing function. Taste, texture, and temperature all impact a patient's swallowing safety. In addition, some patients may not like the taste or texture of barium or may be allergic to it, which can limit the results of a MBSS/VFSS.

Any of these challenges need to be considerations when deciding between FEES and MBSS/VFSS for accurate instrumental evaluation of swallowing. During FEES, real foods and liquids are utilized and specific food items that have been problematic for or preferred by a patient can be tested specifically.

Example patients include: Patients with dementia, patients who are cognitively impaired, patients who have sensory needs, patients who have progressive neurodegenerative conditions/diseases, and patients who have had a stroke

Your patient has reflux or other G.I. issues:

Frequent throat clearing, patient report of a globus sensation or feeling that something is stuck or sticking, and frequent belching, vomiting, or regurgitation of foods/liquids can all have an impact on swallowing.

During FEES, evidence of reflux in the pharynx and larynx (i.e. throat) can be graded using a reflux finding scale. Tissues are viewed directly and findings of swelling, redness/discoloration, mucus, and other anatomical changes are assessed and noted. Regurgitation or backflow can also be viewed as it returns from the upper esophageal sphincter into the pharynx (i.e. returns from the stomach tube into the throat).

From here, if findings consistent with esophageal dysphagia or reflux are present, appropriate recommendations can be made. FEES can be an excellent first step in aiding the clinical management of reflux and its associated symptoms.

It is a misconception that MBSS effectively evaluates the esophageal stage of swallowing. G.I. consult is the appropriate follow-up when esophageal dysphagia is suspected or identified.

You're concerned about the anatomical integrity of your patient's swallowing structures or structural changes are noted in your patient's medical history:

Clinicians who have access to FEES have the advantage of being able to view the patient's generalized vocal cord function, anatomical structures, and presence of obstructing anatomy that may impact functional swallowing (such as swelling or lesions).

FEES can also be used to visualize secretion management, the quality of the patient's oral care and/or suction routine, and can determine if there is possible anatomical pathology that warrants further medical management or follow-up.

Example patients include: Patients with dysphonia or vocal fold paralysis, patients with a history of intubation or throat surgery, patients with a history of radiation, patients who have a tracheostomy, patients who have a nasogastric feeding tube, patients who have GERD or LPR, patients at risk for developing aspiration pneumonia, and patients who have complaints of a globus sensation

FEES versus MBSS/VFSS

How does FEES compare to MBSS/VFSS?

Which one is the "gold standard" in diagnosing swallowing disorders?

Now, why choose FEES? See some examples below:

FEES versus
MBSS/VFSS

Now, why choose FEES?
See some examples below: