Fiberoptic Endoscopic Examination of Swallowing (FEES) Procedure
In 1997 the scope of practice of the New York State Licensure Law in Speech-Language Pathology and Audiology was amended to include the diagnosis and remediation of swallowing disorders. This expansion in the scope of practice allows the licensed Speech-Language Pathologist to treat swallowing disorders. With the inclusion of swallowing in the scope, the New York State Licensure Board has been asked its position concerning a speech-language pathologist performing the flexible fiberoptic endoscopic examination of swallowing (FEES).
The flexible fiberoptic endoscopic examination of swallowing (FEES) is a procedure designed to assess swallowing function through the use of vocal tract visualization and imaging to examine the pharyngeal and laryngeal structures. The fiberoptic endoscopic assessment can be a valuable addition to the evaluation and treatment of the pharyngeal swallow. This procedure enables a trained and skilled speech-language pathologist to evaluate the swallowing impairment as well as appraise the effects of swallowing treatment.
Description of Procedure
A fiberoptic endoscopic evaluation is performed with a flexible endoscope inserted through the nasal passage and passed transnasally into the hypoharynx, often to the level of the valleculae or laryngeal vestibule where the larynx and surrounding structures are viewed. High-intensity light, transmitted by a fiberoptic bundle, illuminates the structure to be viewed and/or recorded by the clinician. The procedure provides an image of the vocal folds, laryngeal and velopharyngeal structures and upper pharyngeal physiology during swallowing, with the potential for image recording and instant replay.
The purpose of the FEES is to assess several specific indicators of an abnormal oropharyngeal swallow including: a) premature spillage into the hypopharynx and laryngeal vestibule prior to swallowing; b) ability of the vocal folds to adduct during coughing, breath holding, and swallowing; c) presence of residue in the hypopharynx and laryngopharynx after a swallow; and d) presence or supraglottic laryngeal penetration or sublottic aspiration. Information may be obtained regarding a patient's ability to protect his airway for swallowing, appropriate diet and postures for feeding, and need for further diagnostic swallowing studies. FEES may also be used as a therapeutic aid and biofeedback tool during the course of swallow treatment.
Advantages and Disadvantages of FEES
The advantages of FEES for swallow function include its relative portability and the ability of the clinician to obtain a clear image of the laryngeal and pharyngeal structures. The examination can be performed in many settings which may not be equipped with specialized and expensive equipment, (e.g. videofluoroscopy) or have specialized medical staff (e.g. radiologist).
The major disadvantage in that flexible endoscopy is an invasive procedure with possible patient discomfort and potential medical risks. Specifically, the procedure may compromise the airway through stenosis or bleeding. At times the patient may become overly sensitive to the procedure and refuse to continue. In rare cases, a patient may unexpectedly go into laryngospasm, experience a vasovagal reaction or respiratory interruption, or go into cardiac arrest during the examination.
The speech-language pathologist who performs FEES must be able to recognize laryngeal and/or pharyngeal pathology. In particular, the speech-language pathologist can be held liable for poor clinical judgment, ie., failure to recognize pathology and make a medical referral. Charges of unprofessional conduct could be brought against the speech-language pathologist who did not recognize such pathology in a patient and make the appropriate referral.
It is the view of the Board that FEES may be performed by a qualified speech-language pathologist. Entry level professional competency, however, is not sufficient to perform flexible nasendoscopy and specifically the FEES. In order to perform this procedure, the speech-language pathologist should have specialized training and clinical experience in the use and interpretation of this technique.
Speech-language pathologists who perform FEES must possess the knowledge, skills and competencies required to perform this instrumental procedure. This special training might include course work, mentorship and/or methodology workshops as well as observation, participation and practitioner must demonstrate knowledge of medical contraindications and knowledge of appropriate actions if complications should occur.
The Fiberoptic endoscopic examination of swallowing (FEES) is a laryngeal and pharyngeal imaging procedure that may be used by speech-language pathologists to assess the physiology and function of the pharyngeal swallow. A physician, however, is the only professional who is licensed by the State of New York to render a medical diagnosis related to the identification of laryngeal and pharyngeal pathology and anatomical abnormality. The properly trained speech-language pathologist is qualified and licensed to assess swallow function.
It is the opinion of the State Board for Speech Language Pathology and Audiology that the Flexible Endoscopic Evaluation of Swallowing procedure, independently performed by a speech-language pathologist as part of an assessment or treatment of dysphagia, falls within the scope of practice as defined by the New York State Licensure Law for Speech-Language Pathology. While the NYS Licensure Law for Speech-Language Pathology does not define procedures that fall within its scope, it does define the practice to include disorders of speech, voice, language or swallowing.