What alternative test can be used instead of a modified barium swallow (videofluoroscopic swallow study) for assessing swallowing in patients who cannot undergo the study?

Alternative Test to Modified Barium Swallow

Fiberoptic endoscopic evaluation of swallowing (FEES) is the recommended alternative to modified barium swallow for assessing dysphagia in patients who cannot undergo videofluoroscopy. 1

Primary Alternative: FEES

FEES should be considered as the first-line alternative when modified barium swallow is unavailable or contraindicated. 1 This recommendation comes from stroke rehabilitation guidelines that explicitly state FEES as an alternative to videofluoroscopic swallowing study (VFSS). 1

Key Advantages of FEES

• FEES can be performed at bedside or in clinic settings, making it highly portable and practical for patients who cannot travel to radiology suites. 2

• The procedure does not involve radiation exposure, unlike videofluoroscopy, making it safer for repeated assessments. 2

• FEES provides direct real-time visualization of pharyngeal and laryngeal anatomy and function before and after swallowing. 2

• FEES is particularly valuable for detecting silent aspiration, which occurs in up to 55% of patients who aspirate without a protective cough reflex. 2

• Research demonstrates that FEES is as sensitive as or even more sensitive than modified barium swallow for detecting aspiration, pharyngeal residue, laryngeal penetration, and pooling of secretions. 3, 4

What FEES Can Assess

• FEES enables comprehensive evaluation of structural abnormalities including laryngeal morphology and motility, velopharyngeal closure competence, and functional deficits such as impaired chewing and tongue muscle weakness. 2

• The procedure identifies safety indicators including pharyngeal residues and secretion pooling, allowing timely intervention to prevent aspiration. 2

• FEES provides direct visualization of anatomy and physiology during deglutition, unlike clinical swallow evaluations which rely on subjective judgments. 2

Important Limitations of FEES

FEES cannot visualize the actual moment of swallowing due to "white-out" when the pharynx contracts, unlike videofluoroscopy which captures the entire swallow sequence. 2 This is a critical limitation when precise timing of swallow events is needed.

FEES cannot assess the oral phase of swallowing, laryngeal/hyoid elevation, upper esophageal sphincter relaxation, or esophageal pathology—all of which are visible on modified barium swallow. 4

The procedure requires adequate patient cooperation and cannot be performed on patients with lethargy, reduced level of consciousness, or inability to manage oral secretions. 2

Clinical Decision Algorithm

When to Use FEES as Alternative:

• Patients who cannot be transported to radiology (critically ill, bedbound) 2
• Patients requiring frequent reassessment where radiation exposure is a concern 2
• Post-stroke patients or those with neurologic conditions where aspiration is suspected 5
• When immediate bedside assessment is needed for rapid clinical decision-making 2

When FEES May Be Insufficient:

• When detailed assessment of oral phase swallowing is required 4
• When upper esophageal sphincter dysfunction needs evaluation 4
• When esophageal pathology must be ruled out 4
• When precise timing of swallow events is critical for treatment planning 2

Complementary Approach

The American College of Chest Physicians recommends that patients with dysphagia should undergo either videofluoroscopic swallow evaluation or FEES to identify appropriate treatment, with a Grade B recommendation. 2 Both modalities are considered valid instrumental assessments for guiding treatment decisions.

Case series comparing FEES and VFSS have shown that each test detects some patients who aspirate that the other test does not, and neither test is clearly better than the other. 1

Common Pitfalls to Avoid

• Do not rely on bedside clinical swallow evaluation alone without instrumental assessment (FEES or VFSS), as bedside evaluations are insufficient to determine treatment interventions for dysphagia. 2

• Do not assume FEES can replace modified barium swallow in all scenarios—recognize that FEES cannot assess esophageal phase or provide tissue diagnosis. 4

• Do not perform FEES on patients with severe lethargy or inability to manage secretions, as adequate cooperation is required. 2

• Remember that 55% of patients who aspirate demonstrate silent aspiration without cough, making instrumental assessment essential rather than relying on clinical signs alone. 2