When you think about using FEES (Fiberoptic Endoscopic Evaluation of Swallowing) in the pediatric population, do you go straight to figuring out how to coax a three year old to munch on some French fries while sitting very still with a camera in his nose? That’s not exactly a walk in the park! Is there even any point in attempting FEES with kids? On the other hand, FEES can give us some information that VFSS (videofluoroscopic swallow study) doesn’t provide and it doesn’t have the added considerations of radiation exposure. So where should a SLP in need of an instrumental swallowing assessment start?
Meister et al. suggests starting with SEES. Yep, you read that correctly: SEES stands for Static Endoscopic Evaluation of Swallowing. This study looked at pediatric records from a clinic that had started implementing SEES. Here’s how it worked: patients (all the way from infants to preteens) were given one bolus to swallow (viscosity based on their current diet and clinical swallow evaluation) and immediately after, the scope was inserted transnasally. This allowed clinicians to visualize the larynx and take note of any residue in the pharynx or visible in the airway after the swallow. If patients were able to tolerate the scope, a full FEES assessment was completed, and all patients completed a VFSS.
By comparing the SEES results with the VFSS results, the authors were able to assess just how useful SEES is as a screening tool. Using gross residue on SEES, they were able to predict 80% of the patients who demonstrated deep penetration or aspiration on VFSS. (But if you’re doing the math, this means that using SEES as a screener would have missed 20% of the patients in this group who had deep penetration or aspiration.) However, in a full third of patients, SEES/FEES also gave the medical team important anatomical information that wouldn’t have been detected in a VFSS (e.g. vocal fold immobility and posterior glottic stenosis)!
Because of these results, the authors stopped short of endorsing SEES as a screener that could rule out the need for a full instrumental evaluation. Instead, they suggest starting with SEES and proceeding to FEES if the child can tolerate the procedure. Then, decide on your treatment plan (or ask for a VFSS) based on the FEES results. If the child is unable to complete the full FEES procedure, you would likely proceed to the VFSS. For all you visual learners, check out Figure 2 for a helpful decision tree. And if you’re wondering if SEES alone is ever appropriate, the discussion section has some great food for thought as to when this might make sense.