What is FEES?
FEES (Flexible Endoscopic Evaluation of Swallowing) is a procedure used to assess a person's ability to swallow safely and efficiently. During the exam, a small flexible tube with a camera is gently inserted through the nose in order to see inside the throat while swallowing. A FEES is performed by a licensed speech-language pathologist (SLP) and allows the SLP to recommend appropriate food and liquid textures as indicated, determine the cause of the swallowing difficulties, and create a treatment plan of care.
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With mobile FEES, the exam is completed in the comfort of the patient's environment (medical facility, outpatient clinic, or home) without the need for transportation to a hospital setting.
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At Nomadic Scope, the speech-language pathologist uses a brand new, state of the art, high definition endoscope to ensure optimal video quality for careful review and identification of abnormalities.
Who is a FEES candidate?
Anyone with signs of difficulty swallowing and in need of an instrumental swallow evaluation is a potential FEES candidate. Some specific diagnoses that have a high risk of dysphagia and would benefit from FEES include:
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Neurogenic disorders such as: Myasthenia Gravis, Parkinson's, Guillian Barre, ALS, MS, Dementia
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Stroke or brain injury
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History of prolonged intubation (>48 hours)
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Head and Neck Cancer
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Tracheostomy +/- ventilator
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Feeding tube dependent
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Limited contraindications for FEES include:
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Severe agitation or combativeness
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Severe bleeding risk/recent severe nose bleeds
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Trauma to the nasal structures from injury or surgery
Benefits of FEES
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Accurate diagnosis of dysphagia
Direct visualization of the swallowing mechanics is necessary in order to make an accurate diagnosis or to rule out dysphagia. Diet modifications and dysphagia intervention should not be provided until instrumentation has been completed.
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"There was a higher prevalence of silent aspiration in thick fluids than thin fluids."
Anna Miles, Mary McFarlane, Samantha Scott, Alexandra Hunting, 2018
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"the bedside swallow exam was found to have a false-positive rate of 70% in detecting aspiration risk, and that it alone underestimates aspiration risk."
​Leder et al., 2002
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Reduced facility costs
A high percentage of patients with perceived dysphagia are on modified diets or feeding tubes without instrumentation. Of those, many are found to be able to consume unmodified food and liquid textures saving overall costs and improving quality of life.
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Average monthly cost of thickening liquids per patient: $200
Robbins J, Gensler G, Hind J, Logemann JA, et al., 2008
Average monthly cost of tube feeds per patient: $2,616
Callahan CM, Buchanan NN, Stump TE, 2001
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Cost-effective exam
FEES involves one fixed rate with no hidden costs, about 75% less than the cost of a Modified Barium Swallow Study (MBSS). An MBSS includes costs for the exam, radiologist fee, transportation to and from the hospital, and lost therapy time while the patient is out of the facility. Because FEES is completed in-house, there are no disrupted treatment sessions.
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Safe procedure
There is no radiation exposure and no risk of injury from frequent transfers. The risk of complications as a direct result of the procedure (i.e. nose bleeds) are 1% according to recent research.
Dziewas, R., auf dem Brinke, M., Birkmann, U. et al., 2019
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Simple billing
The patient's primary SLP can be present for the exam and can bill for dysphagia treatment prior to or after the FEES. Consolidated billing states that a mobile FEES provider may not bill insurance directly while the patient is in a skilled nursing facility. After the FEES, the facility will be billed directly for the procedure.
FEES vs. MBSS
Some key differences between the two exams can make FEES a more desirable approach for dysphagia diagnostics.
A FEES can be scheduled quickly, often within 24 hours of receiving a physician order. Scheduling an MBSS can involve a wait time of a few weeks.
Mobile FEES comes to you! It is completed in the patient's natural eating environment and position. There is no transportation needs or positioning restrictions. The patient's primary SLP can be present for the exam.
FEES is more cost effective, usually costing 75% less than MBSS which can cost an average of $1,400-$1,700. Additionally, there is no transportation cost associated with FEES.
FEES has no time constraints and can be as long the patient requires for a thorough exam. MBSS has a time limit due to radiation exposure.
No lost therapy time as the patient is not required to leave the facility for a prolonged amount of time.
With faster scheduling, intervention and necessary diet modifications can be initiated sooner improving the patient's overall health status and reducing the patient's risk of rehospitalization.
Frequently Asked Questions by SLP's
What if I am confident in my skills to diagnosis dysphagia at bedside?
What if my patient isn't ready for FEES?
With 70% rate of error at the bedside, it is widely known that instrumentation is vital for dysphagia diagnostics. Diet changes and providing therapy without instrumentation increases the patient's risk of complications and can potentially delay care. Here is an example: a patient is coughing with water, is placed on thickened liquids, participates in dysphagia therapy for one month, and later develops pneumonia. Later, FEES reveals silent aspiration of thickened liquids and a laryngeal mass. ENT referral is delayed and the patient has been unsafely consuming thickened liquids.
Delaying instrumental swallow exams impedes a patient's progress and can result in negative implications regarding a patient's health status. Research shows that there is an error rate of 70% when determining presence of dysphagia during bedside swallowing evaluations. Instrumental evaluations are vital prior to treatment or diet modifications in order to provide appropriate care.
What if there is aspiration during the swallow or "white out phase"?
What if my patient won't tolerate FEES?
A misconception is that FEES is painful or difficult to tolerate. In fact, most patients can tolerate being scoped very well. With visual guidance, the scope is inserted gently through the nose. FEES is extremely safe and has been used since 1988. The risk of complications such as nose bleeds (epistaxis), occur in only 1% of cases.
According to research, only 5% of aspiration is known to occur during the swallow. The scope or camera is constantly being positioned to obtain an optimal view of the airway. The sub-glottis is assessed for aspirated material that may have occurred during the swallow. Most aspiration events occur before or after the swallow which can be directly visualized in real time.
How soon can a FEES be scheduled?
A FEES can usually be scheduled with Nomadic Scope Swallowing Diagnostics 24-48 hours upon receiving physician orders. Call, text, or email for information on scheduling a FEES.
What does FEES offer over MBSS?
A FEES can give the SLP insight into various components of the swallow that are not accessible through video fluoroscopy. For example, visibility of secretions, vocal fold mobility, anatomical abnormalities, presence of growths/tumors, and other components of the swallow. FEES is also known to have a higher sensitivity to aspiration than MBSS resulting in more specific recommendations.
Does a patient have to be NPO for FEES?
No, a patient does not have to be NPO (nothing by mouth) prior to the procedure. The patient may continue their current diet until the exam is completed.
About the Owner
Sofia Iturralde M.S. CCC-SLP
owner, endoscopist
Sofia is a medical Speech-Language Pathologist who received her undergraduate and graduate degrees from Baylor University. Sofia spent 6 years of her career in the San Antonio Methodist Hospital where she specialized in the evaluation and treatment of critically ill patients with dysphagia including neurogenic and neurosurgical patients, tracheostomy and ventilator dependent patients, head and neck cancer, and cardiopulmonary, among other populations. She developed a strong passion for FEES and the amazing anomalies she was able to uncover in these patient populations. With a strong passion for evidence-based practice and dysphagia management, she saw a need for mobile FEES in her hometown of Laredo, Texas and founded Nomadic Scope Swallowing Diagnostics, PLLC.
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All recommendations are driven by a holistic understanding of dysphagia taking into consideration the patient’s overall health, exam results, and individualized goals of care. With a commitment to excellent service and swallowing outcomes, Sofia strives to deliver personalized and effective solutions for those seeking optimal swallowing function and improved quality of life.
How to Schedule a FEES
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Service agreement:
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A service agreement must first be established between your facility and Nomadic Scope Swallowing Diagnostics, PLLC
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Physician's order:
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Request an order from the patient's physician for "FEES"
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Intake form:
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Complete an intake form (available for download in "forms" tab) to provide as much information as possible about the patient prior to the evaluation.
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Request appointment:
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Call, text, or email to schedule an appointment. All forms (intake form, order) can be submitted via email.
Click below to download the intake form and submit prior to your appointment.
Contact Us
For any questions about setting up a FEES for your patient or to schedule an in-service to establish a service agreement with your facility, please reach out via text, call, or email.
Address
6318 Krone Ln. Suite #12
Laredo, Texas 78041
Phone
956-693-7089
Connect
@progressiveslp