Which is safer for a patient with aspiration, Modified Barium Swallow (MBS) or Fiberoptic Endoscopic Evaluation of Swallowing (FEES)?

Safety Comparison of Modified Barium Swallow (MBS) vs. Fiberoptic Endoscopic Evaluation of Swallowing (FEES) for Patients with Aspiration

Both Modified Barium Swallow (MBS) and Fiberoptic Endoscopic Evaluation of Swallowing (FEES) are equally safe for patients with aspiration, with neither showing superior safety outcomes in terms of pneumonia incidence or pneumonia-free interval. 1

Comparative Safety Profile

Modified Barium Swallow (MBS)

• Uses water-soluble contrast material (iohexol) which has been shown to be safe even when aspirated 2
• No adverse events associated with aspiration of water-soluble contrast have been reported in clinical studies 2
• Involves radiation exposure, which is a disadvantage compared to FEES 3
• Particularly useful for evaluating the esophageal phase of swallowing 2
• Better for assessing the effect of compensatory postures on swallowing 3

Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

• No radiation exposure, making it safer for repeated examinations 3
• Preferred for patients with Parkinson's disease and other neurological disorders 3
• Better for direct visualization of pharyngeal and laryngeal structures 3
• Superior for detecting pharyngeal residues and structural abnormalities 3
• Requires minimal patient cooperation, advantageous for debilitated patients 3

Clinical Outcomes and Safety Evidence

A randomized prospective study of 126 outpatients with dysphagia showed:

• 18.41% of patients in the MBS group developed pneumonia
• 12.0% of patients in the FEES group developed pneumonia
• The difference was not statistically significant (p = 0.33) 1
• Median pneumonia-free intervals were similar: 47 days for MBS and 39 days for FEES 1

Decision Algorithm for Test Selection

1. Choose FEES when:

   • Direct visualization of pharyngeal and laryngeal structures is critical
   • Patient has cervical stenosis or patulous esophagus 3
   • Repeated examinations are anticipated (no radiation exposure)
   • Patient has neurological disorders like Parkinson's disease 3
   • Evaluating pharyngeal residues is a priority

2. Choose MBS when:

   • Detailed assessment of the esophageal phase is needed 3
   • Evaluation of compensatory postures' effectiveness is required 3
   • Quantitative measurements of cervical esophageal stenosis are needed 3
   • Assessment of the entire swallowing process from oral to esophageal phase is desired

Important Clinical Considerations

• Both tests should be considered gold standards for evaluating swallow function 4
• Both show good agreement in diagnosing tracheal aspiration, laryngeal penetration, and pharyngeal residue 4
• Silent aspiration is common in neurological disorders and may be missed by clinical evaluation alone 3
• Testing with multiple food and liquid consistencies is recommended for comprehensive assessment 3

Practical Implementation

• All stroke patients should have swallow screening before any oral intake 2
• For patients with positive bedside screening, either VFSS/MBS or FEES is appropriate 2
• The diagnostic assessment should identify physiological abnormalities and test treatment strategies 2
• A multidisciplinary approach involving speech-language pathologists, neurologists, and gastroenterologists is recommended 3

In conclusion, both MBS and FEES are safe for patients with aspiration, with no significant difference in pneumonia outcomes. The choice between them should be based on the specific clinical scenario, patient characteristics, and the particular aspects of swallowing function that need to be assessed.