Advocacy, Clinical Focus

The Waiting Game

How long have you had to wait when scheduling a MBSS? Lately, the shortest I have heard is 2 weeks and the longest is 2 months. What do you do in the meantime?

Do you treat the patient based on what you think is happening? This could be beneficial, however, you also might be providing therapy that is ineffective or even unnecessary. But can you wait?

Do you just hang out with the best recommendations you can make until the MBSS can be completed? Make conservative recommendations for diet? We know thickened liquids should not be used without imaging as they are not harmless but what if you think that the patient is aspirating thin liquids?

As I write this, I have no good answers. We have to do the best we can with what we have. 

At Midwest Dysphagia Diagnostics, I know that time matters. I don’t think you or your patients should have to wait and I don’t think your treatment plan should be based on your best guess. 

If you don’t have access to imaging, let me know. I can help you out with mobile FEES in Iowa or direct you to someone in your state. 

1-2 days or 14-60 days. Which sounds better for your patients?

I know I wouldn’t want to wait for treatment and your patients shouldn’t either. 


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Clinical Focus, Education

20 Reasons to Choose FEES

  1. No need to transport the patient out of the facility or even our of their room. Transportation can be very taxing. Some people are worn out before the swallow study even begins. Add in inclement weather and things get even worse. The fragile patient can also stay with the nurses and care team who knows them best. 
  1. The patient can be tested in the position they are usually in when they are eating and drinking. Some people, despite all encouragement not to, will eat and drink in bed. Often times reclined. With FEES, we can complete the test or portions of the test with the patient in this position to determine if it changes the safety and/or efficiency of the swallow. 
  1. There is no time limit. With MBSS, time is limited because of course we can’t radiate people all day. Because FEES does not use radiation, studies can last as long as needed. 
  1. A FEES examination can be completed quickly. We provide the FEES within 24-48 hours of receiving the order. Patients don’t have to wait for care they need. 
  1. There are few to no directions to follow. The patient is given foods and liquids and allowed to swallow naturally instead of at a cued time. This is perfect for patients with cognitive or language deficits. We also get a better picture of how the patient eats and drinks on their own. 
  1. FEES uses real foods and liquids. Nothing other than food coloring is added to the foods and liquids keeping the taste intact. There is no need to change the taste with barium. The patient’s swallow will not be affected by having to eat something that tastes bad. 
  1. There are no size limitations. FEES can be completed on bariatric patients without difficulty. 
  1. The treating SLP can be present for the FEES. In fact, we prefer it! The treating SLP knows the patient best and will be proving the daily dysphagia therapy. We believe that when the SLP can be present, outcomes are improved. 
  1. A report of the findings is left at the facility before we leave. No more long searches for results. We hand deliver full color reports after detailed interpretation of the study. 
  1. Aspiration can be identified early to reduce the risk for serious pulmonary complications. If you have to wait weeks for a MBSS, your patient may be aspirating the whole time which can contribute to pulmonary complications. 
  1. Get a view before and after the swallow. With FEES, the camera never stops rolling. We are able to see what happens both before and after the swallow. This is not possible with MBSS because of the radiation exposure. 
  1. FEES provides a clear view of the laryngeal and pharyngeal structures. In a recent study, incidental findings of laryngeal pathology were found in 39% of FEES examinations (Pazak et al., 2021). Routine FEES examinations can be beneficial for this reason. 
  1. FEES can provide real-time biofeedback. Using biofeedback is an effective strategy in many cases. Patients have also reported a higher level of understanding of their swallowing problem when they can see what they are doing in real-time. 
  1. Compensatory strategies and interventions can be tested to make sure that the patient is able to perform them accurately. An exercise is only effective when completed in the correct way. Instruction can be provided with real-time feedback. 
  1. FEES offers visualization of secretions and secretion management. Poor secretion management and aspiration of secretions is an indicator for risk of pneumonia. 
  1. FEES allows for visualization of the vocal folds. Unilateral or bilateral vocal fold paralysis can be easily identified. 
  1. We use a protocol for our studies which allows for comparison of serial examinations. Some patients will need more than one swallow study while they are receiving dysphagia therapy. Our test allows for direct comparison to gauge progress and improvement. 
  1. FEES can be used to assess the patient over a meal. This can provide an answer to the question of if the patient fatigues or not, and if they do, what happens. 
  1. A nurse can administer the patient’s actual pills during the examination. Many patients report difficulty swallowing pills. We are able to use the actual pills that they have trouble with to determine what can be done to help the patient swallow them easier. 
  1. FEES is highly sensitive and accurate in determining the safety and efficiency of the patient’s swallow in order to quickly determine what intervention is needed. 

FEES is a great tool for use for the above reasons and more. Reply here and let us know how FEES has positively impacted you and your patients. 


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Clinical Focus, Education

Thick or Thin

Thickened liquids are a common intervention recommended by SLP’s. Garcia and Chambers (2008) found that 85% of SLP’s who responded to their survey reported that they believed thickened liquids to be an effective clinical intervention. Of those, 72% reported recommending nectar thick liquids most frequently and 19% reported they recommended honey thick liquids most frequently. This survey did not differentiate the use of thickened liquids as the first choice, second choice, or last choice. I would be very interested in learning more about the choices made by SLP’s in regards to thickened liquids. (Hint hint grad students) 

My first question would be, are we recommending thickened liquids just to eliminate aspiration or are we taking the whole picture into account?

Let’s talk about what the positives of thickened liquids are. Thickened liquids have been shown to reduce prandial aspiration. We know that there is not a simple link from aspiration to pneumonia. Aspiration is just one factor needed for the development of pneumonia. Elimination of aspiration can offer relief to patients who cough excessively with thin liquids. Elimination of aspiration in the short term may also be important for those with very compromised pulmonary status. They may also have utility in the short term for individuals in the acute phase of CVA. 

What about the possible negative consequences? What problems might they create?

Thickened liquids are not very palatable to patients in general. Cichero (2013) found that thickened liquids do not offer satiety of thirst. They do not offer that satisfying mouth feel when you are thirsty and get a drink of cold water. So even if someone drinks enough thickened liquids to achieve adequate hydration, they may not feel satisfied. Thickened liquids also create a feeling of fullness. So combined, people feel thirsty and full at the same time all of the time. 

Thickened liquids can change the way that some medications are absorbed (Cichero, 2013). Medications are designed to be delivered in a specific part of the body at a specific rate and at a specific time. The thickener can also impact the availability of the active ingredients in the drugs. This is all very complicated but just know that there may be an impact. 

Patients that are prescribed thickened liquids may have reduced access to the liquids (Cichero, 2013). Research has shown these patients to have limited access due to reliance on staff to get the liquids, difficulty opening containers of the liquids, or difficulty obtaining the containers of liquids. Patients already don’t like the thickened liquids in general, and limiting access reduces intake even further. 

Dehydration is more common with patients consuming thickened liquids as compared to those consuming thin. Dehydration can cause a wide variety of problems including urinary tract infections, electrolyte imbalance, increased falls, poor muscle strength, and kidney failure among others. When we think about the whole patient, we need to think about the risks associated with dehydration. 75% of patients on thickened liquids were found to be dehydrated in a 2001 study by Finestone et al. 

Aspiration of gastric contents is very dangerous and can quickly lead to respiratory infection and or failure. Thickened liquids increase reflux and subsequently increase risk of aspiration of that refluxed material. 

All together, it’s clear that recommending thickened liquids is not a black and white decision. We need to think beyond just aspiration. My recommendation would be to avoid recommending thickened liquids whenever possible and to use thickened liquids as a tool to bridge a patient over into safe consumption of thin liquids by providing aggressive, evidence based dysphagia treatment. 

One final thought: I would challenge all SLP’s to consume only thickened liquids for an entire day. Maybe even consume just honey-thick liquids. I think this would be an interesting experiment and may offer more insight into the experience of our patients. 




Cichero J. A. (2013). Thickening agents used for dysphagia management: effect on bioavailability of water, medication and feelings of satiety. Nutrition journal, 12, 54.

Finestone HM, Foley NC, Woodbury GM, Greene-Finestone L. Quantifying fluid intake in dysphagic stroke patients: a preliminary comparison of oral and nonoral strategies. Arch Phys Med Rehabil. 2001;82:1744–1746. doi: 10.1053/apmr.2001.27379.

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Advocacy, Clinical Focus, Education

What Does ASHA Say?

ASHA, our governing body provides us guidance for clinical decision making. Below is the information they provide for adult dysphagia assessment. Note that the bolded text is from ASHA and the unbolded text is my own thoughts. 

Instrumental Swallowing Assessment

SLPs use instrumental techniques to evaluate oral, pharyngeal, laryngeal, upper esophageal, and respiratory function as they apply to normal and abnormal swallowing. In addition, instrumental procedures are used to determine the appropriateness and the effectiveness of a variety of treatment strategies.

Instrumental techniques are usually conducted either independently by the SLP or by the SLP in conjunction with other members of the interprofessional team (e.g., radiologist, radiologic technologist, physiatrist). Competence in videofluoroscopic swallowing study (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES) requires appropriate training and education. SLPs help guide medical decision making regarding the appropriateness of these procedures given the severity and nature of the patient’s swallowing deficits. SLPs interpret and apply the results of objective testing to the formulation of dysphagia treatment plans, and they also determine patient capacity and safety for oral feeding.

Indications for an instrumental exam include the following:

  • Concerns regarding the safety and efficiency of swallow function
    • Contribution of dysphagia to nutritional compromise
    • Contribution of dysphagia to pulmonary compromise
    • Contribution of dysphagia to concerns for airway safety (e.g., choking)


At times we may fall into the trap of focusing in too closely on the patient’s dysphagia only. We have to remember to look at the entire picture, look at the patient as a whole. When we collaborate with the medical team, the outcomes can only improve for the patient. 


  • The need to identify disordered swallowing physiology to guide management and treatment

We can’t treat what we can’t see. Let me say that again. We can’t treat what we can’t see. 

  • Inconsistent signs and symptoms in the findings of a non-instrumental examination

Remember that there is not always a cough response to aspiration. And sometimes, there will be a cough with aspiration of thin liquids but no cough with thickened. We can’t depend on the bedside swallow evaluation to determine when aspiration happens. 

  • The need to assist in the determination of a differential medical diagnosis related to the presence of pathological swallowing

SLP’s can sometimes be the first medical professional to identify signs/symptoms of a neurological condition. 

  • Presence of a medical condition or diagnosis associated with a high risk of dysphagia

Think CVA, TBI, COPD, HANC, Parkinson’s Disease, Progressive neurological conditions, MS, dementia, etc. 

  • Previously identified dysphagia with a suspected change in swallow function that may change recommendations

If there is a change in status for a patient with known dysphagia, an instrumental swallow study is warranted and needed whether it is a change for the better or for the worse. 

  • Presence of a chronic degenerative condition with a known progression or the recovery from a condition that may require further information for the management of oropharyngeal function

We are an important part of the care team for these patients. 

Contraindications for an instrumental exam include the following:

  • The patient is not medically stable enough to tolerate the procedure.
  • The patient is not able to participate in an instrumental examination (e.g., cognitive difficulties, inability to maintain an appropriate level of alertness).
  • The SLP’s clinical judgment indicates that the instrumental assessment would not change the clinical management of the patient.

Similar to non-instrumental assessment, instrumental assessment also includes a thorough case history; an oral mechanism exam; and assessment of overall physical, social, behavioral, and cognitive/communicative status (see previous section on Non-Instrumental Swallowing Assessment for details on these components of an evaluation). 

The purpose of the instrumental examination is to enable the SLP to

  • visualize the structures of the upper aerodigestive tract;
  • assess the physiology of the structures involved in swallowing and to make observations, measures, and inferences of symmetry, sensation, strength, pressures, tone, range of motion, and coordination or timing of movement to determine the diagnosis of dysphagia;
  • determine presence, cause, and severity of dysphagia by visualizing bolus control, flow and timing of the bolus, and the individual’s response to bolus misdirection and residue;
  • visualize the presence, location, and amount of secretions in the hypopharynx and larynx, the patient’s sensitivity to the secretions; and the ability of spontaneous or facilitated efforts to clear the secretions;
  • determine the cause(s) for laryngeal penetration and/or aspiration; and
  • determine with specificity the relative safety and efficiency of various bolus consistencies and volumes.

You can see above that at no time does ASHA recommend that a clinician only rely on a bedside swallow examination when there is suspected dysphagia. We can’t treat what we can’t see. Mobile FEES with Midwest Dysphagia Diagnostics provides easily accessible, high quality instrumental examinations for your patients and residents. Reach out today!

American Speech-Language-Hearing Association. (n.d.). Adult Dysphagia. (Practice Portal). Retrieved month, day, year, from

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Advocacy, Clinical Focus, Education

With a Little Help From My Friends

In past blogs and social media posts, I have offered help in whatever way I can. I believe strongly that we should help each other instead of being competition. In that spirit, I want to share more specific ways I can offer help and assistance. Check out the list below and if you feel like you could benefit, please reach out! 


Have you been asked by your facility to provide an inservice? Feel like the staff at your building could benefit from a refresher on dysphagia? Not sure where to start? Midwest Dysphagia Diagnostics provides free inservice to facilities. We are prepared to speak on dysphagia in general, diet consistencies, how to fill out section K, or how FEES could benefit the facility and residents. We are ready to provide the entire inservice or collaborate with you. We’ll even bring the snacks! 


Have a difficult dysphagia case that you aren’t quite sure what to do with? Need some resources? Reach out! We have a large library of EBP articles ready for you to implement in your practice*. Ran into a diagnosis you have never seen before? Let us know! We can talk about dysphagia all day. 

FEES Advocacy Help

Are you ready to implement FEES in your facility but not everyone is on board yet? Are they still in the dark as to the benefits of FEES? The information they need is right here. We have compiled the latest research and cost/benefit analysis material to show the staff in your facility. Getting the needed instrumental assessments to all patients is our passion and mission. Let us help you show the value and necessity of FEES. And again, we will bring the snacks!


Just feel like you need to vent? Looking for that one article that you can’t find*? Questions about MDTP? Want to do a job shadow? Reach out! We would love to hear from you. 

Remember it is community over competition and we are all stronger together. 




*We only provide full text versions of open access articles. 

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Advocacy, Clinical Focus

What to do when the answer is no

I’m sure many of us have run into the problem where we ask for an instrumental swallow evaluation and we are told no whether it is nursing, the administrator, or the NP writing the orders. What then?

Let’s go through an example. Let’s say that a new admit to your facility arrived following a stroke. This patient did not have an instrumental swallow evaluation at the hospital because by the time it was appropriate, the patient was discharged to your facility. You complete the clinical swallow examination and administer the Yale 3oz Water Protocol. The patient is not able to pass. So you do what is supported by the evidence and ask for an instrumental examination. Then you are told no. 

What next? You provide evidence and education on why an instrumental swallow study is necessary for treatment. You explain why just putting the patient on thickened liquids is a terrible solution. You explain how getting a FEES would actually make the facility money because it would offer the proof needed for continued treatment. And still, the answer is no. 

So what are the options? 

1. You could just treat without the instrumental. You could guess which exercises may help and guess what would be the safest and most appropriate for the patient. You could just hope that what you are doing is keeping the patient safe. Not a great option…

Or 2. You could say that you can not ethically and effectively provide dysphagia therapy without imaging and so you are forced to discharge the patient. 

Does #2 cause anxiety? You might say, “well we can’t just not treat the patient.” I would ask, how do you know your “treatment” is doing more good than harm? How do you know it is making things better instead of worse? How do you know that the patient even needs treatment? 

What if the doctor never took your blood pressure but put you on a blood pressure medication “just in case?” How would you feel if your orthopedic surgeon decided to do knee surgery without imaging because “You probably need it?” Not great. 

So why do we allow this to happen with our dysphagia patients? Until we stop providing treatment without imaging, we will continue to hear “no.” Let’s change this for our patients. 


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Case Study, Clinical Focus

The Case Files: ACDF

This week I want to share an interesting case study. This is about a patient that I saw when I was previously working in acute care. Diagnostics there were video fluoroscopic imaging, not FEES, but we know it’s never FEES versus VFSE. It’s FEES and/or VFSE. 

The patient was a 65 YOM who just completed ACDF. I apologize that I don’t remember the exact details of the surgery. This patient was complaining of pain and difficulty with swallowing. On first thought, we know that almost everyone who has this surgery will have temporary difficulty with swallowing due to edema, however, this seemed more severe than most cases. 

I went and saw the patient, and like I said most patients have some edema, but this gentleman had major edema. On the right side, you could not see where his chin ended and his neck began. In consultation with the care team, the doctor reported he had already finished his course of steriods. 

During the interview, the patient reported that he felt like he could not swallow anything and when he took a small sip, he felt like it was “going the wrong way” and it made him cough every time. He also reported after he swallowed that he felt pain in his neck. When I asked where the pain was, the patient pointed to his neck lateral to midline. He described the pain as a burning sensation. He said it really only burned after he swallowed. 

The patient completed an oral motor examination and the only significant finding was the edema. With oral trials, the patient did demonstrate immediate coughing regardless of consistency. No regular solids were attempted as the patient was on a full liquid diet per medical team. With sips of thin liquids, the patient swallowed up to six times, coughing in-between swallows, and breath quality was wet. At this time, I made the recommendation for a VFSE. Unfortunately, this referral came in late in the day and the VFSE would not be completed until the next day. 

The VFSE revealed internal edema which restricted bolus flow and caused aspiration. This was not surprising based on his clinical appearance. Positioning changes were ineffective in improving bolus flow. The patient completed three trials of thin liquids when the cause revealed itself. Contrast began to show up lateral to the pharynx, right where the patient said that he felt the burring. He had a fistula from the surgery. He was quickly taken for a CT scan and then flown to a higher level of care. 

So while this case is very interesting, I think it also sheds light on the importance of instrumentation. Had I just assumed it was the “regular” swelling from the surgery, the fistula may not have been discovered until later, when there could have been serious consequences. Now, I am not of course saying every ACDF patient needs imaging, but when there are unique symptoms, imaging is always the best choice. 

What unique cases have you encountered? What incidental findings have you seen?


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Clinical Focus

Seeing is Believing

A new article came out recently  that highlights another reason why FEES can be important for patients in the medical setting. This study in particular looked at patients in a community hospital. Researchers looked at the FEES results from 75 patients to determine how often incidental findings were seen. These patients were included in the study if they failed a swallow screening by nursing.

A total of 29/75 patients had incidental findings. 29 people had something identified that would have gone unknown without the FEES. 29 people that may not have been receiving the interventions they needed.

I myself have found possible carcinoma or tumor multiple times. I have seen paralyzed vocal folds that were unknown to the patient and their care team.  I have also seen possible infections and signs of reflux.

So what does this mean for us? I think it tells us that we need to think more broadly about the purpose and rational for a FEES. If the patient had been intubated, a FEES is very appropriate and perhaps necessary for a full evaluation of that patient. Many times, visualizing the structures and tissues reveals the cause of the dysphagia or a contributing factor. Of course, the FEES examination is for swallowing, not a test to detect cancer or other conditions but its purpose extends past just checking for aspiration or penetration.

Remember we can’t treat what we can’t see. Let’s all take a look together. 


Pazak, J., Bhatt, N. K., Levy, A., Schick, S., & O’Dell, K. (2021). Incidental Laryngeal Findings on Bedside Flexible Endoscopic Evaluation of Swallowing in a Community Hospital Setting. The Annals of otology, rhinology, and laryngology, 3489420987201. Advance online publication.

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Clinical Focus

Update on COVID Precautions and Can You Scope a COVID+ Person? (Yes!)

The top priority during this time is doing everything I can to help stop the spread of COVID-19. Safety and infection control are incredibly important. The precautions below were established with consult from infection control specialists as well as recommendations from the CDC and the Iowa Public Health Department. I am happy to provide a copy of the Infection Control Policies and Procedures on request.

Enhanced Infection Control

  • All equipment used is hard surface so if can be disinfected
  • All equipment is cleaned a minimum of two times before it enters your facility
  • All CDC recommendations for disinfection are followed
  • All disinfectants used are specified for use to kill COIVD-19

Changing the Way We Do Things

  • I visit only one facility each day to prevent transmission from one facility to the next
  • I wear PPE to airborne standards
  • I follow your facility’s PPE regulations
  • Time spent in the facility is kept to a minimum
  • I am happy to complete the test in a room of your choice

Keeping Ourselves Safe

  • I am tested for COVID at least twice weekly
  • I am happy to take a test at your facility before entering if requested
  • I participated in the Pfizer Vaccine trial and have received both doses of the vaccine
  • Time spent in public spaces is very limited. Masks are always worn and social distancing precautions closely followed.


  • Can you order a FEES for a person that is COVID+?

Yes you can! We have the necessary PPE to keep ourselves and the SLP at the facility safe. Dysphagia hasn’t stopped because of COVID and we have never stopped providing FEES to these patients.

  • Can we enter a building with an active outbreak?

Yes we can! Again, we have the proper PPE needed to stay safe.

  • Do I need to wait until a patient is done with the two week quarantine before ordering a FEES (COVID+ or not)?

Nope. Let’s get them the care they need as soon as possible.

  • Are you willing to take a test at the facility before entering?

Of course! I am always happy to follow any and all precautions specific to your facility.

  • I don’t know the precautions for scoping a patient who might have COVID-19. Can you help? 

Of course! I am happy to review the procedure before I come to make sure you feel completely comfortable.

  • My administrator/DON/DOR/etc is not completely comfortable letting someone in the facility. What can I do?

Let me know! I can speak with them and review all of the precautions in place and answer all of their questions.

As always, please reach out with questions or concerns. And of course, #ScopeOn


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