How to Order a FEES Test
Refer patients requiring FEES evaluation directly to a Speech-Language Pathologist (SLP), as they are the ideal professionals to perform and interpret this examination. 1
Ordering Process
Primary Referral Pathway
- Order to: Speech-Language Pathology Department
- Consultation type: Request for "oral-pharyngeal swallow evaluation" or specifically "FEES examination"
- The ACCP guidelines explicitly state that patients with oral-pharyngeal dysphagia should be referred "ideally to a speech-language pathologist (SLP)" for swallow evaluation 1
Collaborative Model
In many institutions, FEES is performed through teamwork between an SLP and an otolaryngologist working together 2. Some centers have established Voice and Swallowing Disorders clinics where this collaboration is formalized. However, the SLP remains the primary professional for swallow evaluation per guideline recommendations.
Alternative Pathways
- ENT/Otolaryngology: In some institutions, you may order through ENT, particularly if they have a dedicated swallowing disorders clinic 3, 2
- Neurology: For neurogenic dysphagia, some neurology departments perform FEES at bedside 4
When to Order FEES
High-Priority Indications (Grade B Recommendations)
Order FEES evaluation when patients have:
- Cough with swallowing problems reported by patient or caregiver 1
- High-risk medical conditions including stroke, neurological diseases, head/neck cancer, or conditions listed in the guidelines 1
- Cough related to pneumonia/bronchitis with aspiration risk factors 1
- Clinical signs of aspiration: wet voice, throat clearing, dysphonia after swallowing, dysarthria, or coughing during water swallow test 1
- Nutritional compromise: malnutrition, unintentional weight loss, feeding tube in place 1
- Abnormal chest x-ray with patchy opacity, lower lobe infiltrate, or aspiration 1
Contraindications to FEES
Do not order FEES if patient has:
- Lethargy or reduced consciousness
- Absent swallow response on command
- Abnormal upper airway sounds
- Inability to manage oral secretions (requiring frequent suctioning)
- Respiratory rate >35 breaths/min
Key Advantages of FEES
- Portable/bedside examination - can be performed in ICU or at point of care 4
- No radiation exposure - safe for repeated examinations 4
- Direct visualization of pharyngeal and laryngeal structures during actual swallowing 3, 2, 5
- Can assess real food and liquids from patient's normal diet 1
- More specific than videofluoroscopy for detecting aspiration (75-100% specificity) 6
Common Pitfalls to Avoid
- Don't delay referral waiting for "objective" bedside tests - if clinical suspicion exists based on history and observation, refer for instrumental evaluation 1
- Don't order FEES on lethargic or obtunded patients - they need to be alert first 1
- Don't assume absence of cough means no aspiration risk - silent aspiration is common in neurological patients