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Instrumental swallowing evaluations are used in order to see if a patient is swallowing safely. Unsafe or deficient swallowing can lead to food or liquid going into the airway, causing aspiration pneumonia. There are two types of instrumental swallowing assessments: the Modified Barium Swallow (MBS) and the Fiberoptic Endoscopic Evaluation of Swallowing (FEES)/ Fiberoptic Endoscopic Evaluation of Swallowing and Sensory Testing (FEESST). Both assessments are performed with various consistencies of solids and liquids in order to see how the patient is able to manipulate each consistency. These include thin liquid, nectar-thick liquid, honey-thick liquid, puree, soft solids, and hard solids.

The Modified Barium Swallow (MBS) is considered the “Gold Standard” in swallowing assessments. It is performed with a specified x-ray machine in a radiology suite with the speech-language pathologist, radiology technician, and the radiologist in the room. Radiation exposure is a disadvantage of this assessment, so all parties involved have to wear safety equipment (lead smock, thyroid guard, etc). The patient is either sitting in a chair or standing behind the x-ray screen, and is fed various foods comprised of different consistencies in order to see which consistencies can be tolerated. All of the food and liquids are mixed with barium in order to allow it to be seen on the x-ray screen. The speech pathologist/radiologist can see all of the swallowing phases on the screen, including the patient taking in the food, manipulating the food in their oral cavity, the food transferring from the oral cavity to the pharynx, passing through the pharynx, and into the esophagus

Advantages:

• Can view all phases of the swallow (oral, pharyngeal, and esophageal)
• Not invasive

Disadvantages:

• Radiation exposure
• Not portable
• Possible aspiration of barium
• Scheduling can be delayed
• Does not give visual input regarding structures (i.e., vocal folds) or secretions

The Fiberoptic Endoscopic Evaluation of Swallowing (FEES) and the Fiberoptic Endoscopic Evaluation of Swallowing and Sensory Testing (FEESST) are extremely similar; the only difference is that during the FEESST, the camera gives off a small puff of air testing the sensory reflexes of the structures. Swallowing is both sensory and motor, so the patient needs the sensory component in order to have an adequate swallow. The FEES/FEESST can be performed almost anywhere, as this equipment can be portable. This assessment is performed via a flexible endoscope, or a long and thin tube-like camera, that goes through the patient’s nose and into the throat. This angle allows the speech-language pathologist (or doctor, ENT, etc.) to have a bird’s eye view of the larynx (voice box), or allowing them to look directly down at it. The larynx is supposed to close completely during swallowing in order to protect the patient’s airway, and this angle allows the assessing professional to see the closure of the larynx, as well as the function of the structures in the throat. With this angle, pooling, stasis, residue, and reflux can be seen as well. The image can be viewed on a nearby monitor or computer screen as the SLP is performing the test.

Advantages:

• No radiation
• Portable (can be done at the patient’s bedside)
• Excellent view of anatomy for information (for secretion management, reflux, etc.)

Disadvantages:

• Invasive/not very comfortable for the patient
  • Not ever patient will tolerate the scope (very young, cognitively impaired, etc.)

• Does not provide information on all stages of swallow (only pharyngeal – not oral or esophageal)

After an instrumental swallowing evaluation, the speech-language pathologist will be able to assess which consistencies are safest for the patient to eat at that time, and possibly implement swallowing therapy or a treatment plan to strengthen their swallow.

Resource: Dr. Cathy Crowley, Lecture @ Adelphi University, 2017

-Jessica Eberhart M.S., CF-SLP, TSSLD