Fiberoptic endoscopic evaluation of swallowing: where should we go from here?

Fiberoptic endoscopic evaluation of swallowing (FEES), proposed by Langmore et al. in 1988(¹), revolutionized instrumental swallowing assessment by providing practical advantages and significantly contributing to clinical decision-making in oropharyngeal dysphagia. Since then, numerous studies have described — albeit in a non-standardized protocol — the methods of execution, the use of dyes, volumes, and utensils, as well as the scales for analysis and measurement(²-⁴). If there is a consensus in the literature, it is the absence of a universal protocol(⁵). Study populations, contexts of application, and, above all, the experience of the professional who performs and interprets the exam are all heterogeneous. Thus, they directly impact the possibilities of standardization and the genuine contributions of FEES to the diagnosis and rehabilitation of oropharyngeal dysphagia.

Having been consolidated for decades, we know how to perform the test(⁶-⁸). However, a recurring theme in scientific conferences and publications is the continued exploration of the same fundamental points, despite the field's technical and scientific maturity. Criticism is needed: the insistence on debating how to do it has overshadowed the question that truly matters at this moment: “What to do with what we find?”. Therefore, this authors’ comment aims to encourage readers to reflect on the necessary change in FEES perspectives in a direction that truly impacts clinical decision-making across different patient profiles.

We currently observe an academic world that continuously revolves around the same thematic axes without any substantial progress, including whether dye is used or not, the choice of utensils, patient positioning, and classification scales, which have already been described in the literature. If we remain entrenched in the same discussions, we will not only be stagnant but also overlook the potential for advancement in an area that still has much to offer regarding clinical reasoning, therapeutic tests, and individualized intervention planning. It is in this still unexplored space (i.e., questions that have not yet been formulated about clinical reasoning and decision-making) that the true FEES advancement lies, rather than repeatedly reproducing already known answers about the performance of the exam.

Findings such as posterior oral spillage, pharyngeal residues, penetration, and aspiration should not only be described or classified using scales that quantify their severity. In this way, the discussion still remains an observation that values the bolus rather than the physiology of swallowing . Such findings need to be interpreted by a swallowing specialist and related to the underlying pathophysiological mechanisms to support more informed decision-making based on the patient's profile(⁹). In conclusion, no examination in dysphagic patients is conclusive, as these assessments show what happened but do not explain why. Therefore, the discussion on FEES should move beyond aspects related to the bolus, allowing for a better understanding of the underlying causes of the findings and providing stronger support for clinical decision-making in dysphagia.

• Study conducted at Laboratório de Disfagia, Departamento de Fonoaudiologia, Universidade Estadual Paulista – UNESP - Marília (SP), Brasil.
• Financial support:
  nothing to declare.
• Data Availability:
  No research data was used.
• Use of artificial intelligence-assisted technology
  The authors declare that no artificial intelligence tools were used in the research reported here or in the preparation of this article.

REFERENCES

• ¹ Langmore SE, Kenneth SMA, Olsen N. Fiberoptic endoscopic examination of swallowing safety: a new procedure. Dysphagia. 1988;2(4):216-9. https://doi.org/10.1007/BF02414429 PMid:3251697.
  » https://doi.org/10.1007/BF02414429
• ² Curtis JA, Seikaly ZN, Dakin AE, Troche MS. Detection of aspiration, penetration, and pharyngeal residue during flexible endoscopic evaluation of swallowing (FEES): comparing the effects of color, coating, and opacity. Dysphagia. 2021;36(2):207-15. https://doi.org/10.1007/s00455-020-10131-0 PMid:32394024.
  » https://doi.org/10.1007/s00455-020-10131-0
• ³ Butler SG, Stuart A, Case LD, Rees C, Vitolins M, Kritchevsky SB. Effects of liquid type, delivery method, and bolus volume on penetration-aspiration scores in healthy older adults during flexible endoscopic evaluation of swallowing. Ann Otol Rhinol Laryngol. 2011;120(5):288-95. https://doi.org/10.1177/000348941112000502 PMid:21675583.
  » https://doi.org/10.1177/000348941112000502
• ⁴ Swan K, Cordier R, Brown T, Speyer R. Psychometric properties of visuoperceptual measures of videofluoroscopic and fibre-endoscopic evaluations of swallowing: a systematic review. Dysphagia. 2019;34(1):2-33. https://doi.org/10.1007/s00455-018-9918-3 PMid:30019178.
  » https://doi.org/10.1007/s00455-018-9918-3
• ⁵ Prikladnicki A, Santana MG, Cardoso MC. Protocols and assessment procedures in fiberoptic endoscopic evaluation of swallowing: an updated systematic review. Braz J Otorhinolaryngol. 2022;88(3):445-70. https://doi.org/10.1016/j.bjorl.2021.03.002 PMid:33895102.
  » https://doi.org/10.1016/j.bjorl.2021.03.002
• ⁶ Langmore SE. History of fiberoptic endoscopic evaluation of swallowing for evaluation and management of pharyngeal dysphagia: changes over the years. Dysphagia. 2017;32(1):27-38. https://doi.org/10.1007/s00455-016-9775-x PMid:28101663.
  » https://doi.org/10.1007/s00455-016-9775-x
• ⁷ Schindler A, Baijens LWJ, Geneid A, Pizzorni N. Phoniatricians and otorhinolaryngologists approaching oropharyngeal dysphagia: an update on FEES. Eur Arch Oto-Rhino-Laryngol. 2022;279(6):2727-42. https://doi.org/10.1007/s00405-021-07161-1 PMid:34779927.
  » https://doi.org/10.1007/s00405-021-07161-1
• ⁸ Langmore SE, Scarborough DR, Kelchner LN, Swigert NB, Murray J, Reece S, et al. Tutorial on clinical practice for use of the fiberoptic endoscopic evaluation of swallowing procedure with adult populations: Part 1. Am J Speech Lang Pathol. 2022;31(1):163-87. https://doi.org/10.1044/2021_AJSLP-20-00348 PMid:34818509.
  » https://doi.org/10.1044/2021_AJSLP-20-00348
• ⁹ da Silva RG, Alves TC, Cola PC, Pernambuco L, Magalhães Júnior HV, Furkim AM, et al. Re-thinking fiberoptic endoscopic evaluation of swallowing for clinical decision-making in oropharyngeal dysphagia: an expert opinion. Arq Gastroenterol. 2024;61:e24018. https://doi.org/10.1590/s0004-2803.24612024-018 PMid:39442122.
  » https://doi.org/10.1590/s0004-2803.24612024-018

Edited by

• Editor:
  Ana Carolina Constantini.

Data availability

No research data was used.

Publication Dates

• Publication in this collection
  01 June 2026
• Date of issue
  2026

History

• Received
  24 Sept 2025
• Accepted
  26 Oct 2025