November 24

How to Advocate for FEES Part II: You Can’t Treat What You Can’t See


This is the second part in a three part series about how to advocate for FEES. If you missed the first part, check it out. It’s all about the money side of things. This post will focus more on the clinical side of things. 

I think we SLP’s have done ourselves a disservice by accepting that instrumental swallow studies are difficult to get approved in the SNF setting and so many give up and just rely on the clinical swallow examination. Administrators may be used to the previous SLP never asking for a swallow study and then you come in armed with your EBP and they wonder why you are so much worse at your job because the last SLP could do these things at the bedside. (Insert deep sigh here). 

I think we need to remember that WE are the experts in dysphagia, not the administrator, so we have the responsibility to effectively advocate for our patients. No one really likes to admit they were wrong but sometimes that is exactly what we need to do. We need to say we used to think that way, that the bedside or clinical swallow examination was sufficient, but now we know better and we know we were wrong. 

The research shows that most of the measures we use during a clinical swallow examination are not reliable or based on actual research. For instance, palpating for hyolaryngeal elevation and excursion is very unreliable. It is impossible to reliably diagnose “reduced hyolaryngeal elevation and excursion” at bedside. Cervical auscultation is another technique that has been debunked as unreliable. Mathers-Schmidt and Kurlinski (2003) found a high level of inconsistency when they surveyed medical SLP’s. I completed a brief search on this topic and found similar articles from all over the world. So while I do think that the clinical swallow examination is important and useful, we should not base our recommendations and treatment plans on it. We can’t treat what we can’t see and we need to stop doing exactly that. 

So back to advocacy! I am always willing to say what I don’t know. When the nurse asks me what diet someone should be on, I am ready to answer with, “I don’t have all the information I need to make that recommendation.” (I think a more professional way of basically saying I don’t know). Next, explain that we need a FEES. I might say, “I am guessing that this individual has pharyngeal dysphagia but I can’t know for sure until I see it.” If I am almost sure that there is an issue (say the person coughs and coughs after every time they take a drink) I still don’t know the why. I don’t know what the physiological deficit is. If I don’t know what I am treating, there is no way that I would do a good job at treating it. 

Some other common facts from the literature I share are:

  • Patients with dysphagia may cough when they aspirate thin liquids but have no cough response when aspirating thickened liquids. So at bedside if we give our patient a trial of thin liquids and they cough, then a trial of nectar-thick and they don’t, it does not necessarily mean that the nectar-thick is safe. We need the instrumental to know. 
  • We over-diagnose dysphagia 70% of the time (Leder, 2002). This can be costly which you can learn all about in the previous post. 
  • We miss silent aspiration. How could we know this at bedside?

So let’s take a look at a specific situation to illustrate what we don’t know from a clinical swallow examination. Let’s say you have a patient and they cough after they drink thin liquids during your examination. First, we can’t even be sure that they were aspirating. And if they were, did it happen before, during, or after the swallow? Is it a timing issue? Is it from incomplete airway closure? Is it because of residue? If they are aspirating what strategy will help? Chin down? Head turn? Effortful swallow? Supraglottic swallow? I know I am sounding like a broken record but we don’t know. How do we find out? FEES of course!

Once we demonstrate why we need the instrumental, the administrator who might not know much or anything about dysphagia will understand why you are actually better at your job and not worse. 

Next time I will focus on how we show the benefits of including FEES. 

If you want to get your hands on my concise guide for advocacy, comment below or reach out to


Leder, S., Espinosa, J. Aspiration Risk After Acute Stroke: Comparison of Clinical Examination and Fiberoptic Endoscopic Evaluation of Swallowing . Dysphagia 17, 214–218 (2002).

Mathers–Schmidt, B.A., Kurlinski, M. Dysphagia Evaluation Practices: Inconsistencies in Clinical Assessment and Instrumental Examination Decision-Making . Dysphagia 18, 114–125 (2003).


Advocacy, Dysphagia, FEES, SLP, Swallowing

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