Hearing, Balance and Communication

ISSN: 2169-5717 (Print) 2169-5725 (Online) Journal homepage: https://www.tandfonline.com/loi/ihbc20

The endoscopic evaluation of the oesophageal

phase of swallowing (E-FEES): perspective in a
audiological-phoniatric setting

Daniele Farneti & Elisabetta Genovese

To cite this article: Daniele Farneti & Elisabetta Genovese (2019) The endoscopic evaluation of
the oesophageal phase of swallowing (E-FEES): perspective in a audiological-phoniatric setting,
Hearing, Balance and Communication, 17:3, 197-202, DOI: 10.1080/21695717.2019.1603950

To link to this article: https://doi.org/10.1080/21695717.2019.1603950

Published online: 02 May 2019.

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HEARING, BALANCE AND COMMUNICATION
2019, VOL. 17, NO. 3, 197–202
https://doi.org/10.1080/21695717.2019.1603950

CASE REPORT

The endoscopic evaluation of the oesophageal phase of swallowing

(E-FEES): perspective in a audiological-phoniatric setting
Daniele Farnetia and Elisabetta Genoveseb
a
Audiology and Phoniatry Service, Infermi Hospital, Rimini, Italy; bAudiology Service, University of Modena and Reggio Emilia,
Policlinico Hospital of Modena, Modena, Italy

ABSTRACT KEYWORDS
During a fiberoptic endoscopic evaluation of swallowing (FEES) the study of the oesophagus, E-FEES; TNE; dysphagia;
complete with tests with bolus (oesophageal FEES, E-FEES) is a procedure rarely used in a phoni- deglutition disorders; voice
atric setting, with patients complaining of swallowing and voice alterations. This extension of alterations
FEES toward the oesophagus by a transnasal approach is a procedure used for decades in the
instrumental evaluation of patients with ENT complaints. E-FEES is used on out-patients without
premedication or local anaesthesia. The patient is sitting upright and a 70 cm flexible endoscope,
3.5 cm diameter, is used. During the procedure the patients undergo tests with bolus. 20 patients
(13M/7F, range 19–78 years, mean age 50, 51 years), taken from 437 consecutive outpatients
seen in our Department from August to December 2011, underwent E-FEES (retrospective ana-
lysis). Patients were selected based on a reflux finding index (RFI) > 13, Reflux finding score
(RFS) > 7 and FEES alterations (penetration/aspiration, spillage, residues). E-FEES findings were: 10
esophagitis, 1 gastroesophageal junction incontinence, 2 hiatal hernia, 4 motility alterations, 2
diverticula, 1 carcinoma. oesophageal alterations are not rare in patients with deglutition and
voice disorders. E-FEES is a safe, reliable and cost-effective technique, worthy of being imple-
mented in a phoniatric setting. The main steps and characteristic of the procedure are proposed.

Introduction esophagoscopy – TNE). TNE is a procedure which

The possibility of a complete direct viewing of the
upper aero-digestive tract, involved in all its activities,
represents a valuable resource, which is not suffi-
ciently widespread nowadays in clinical practice in
patients with voice and swallowing complaints. When
such a comprehensive evaluation is needed, the possi-
bility of performing an endoscopic evaluation of the
oesophageal phase of swallowing is a desirable goal in
the clinical daily practice of a Swallowing Center.
The number of patients complaining of swallowing
disorders due to or influenced by a low aetiology (also
as a co-morbidity factor) is constantly increasing [1].
Conversely, a transnasal approach to the upper
digestive tract has been known for decades, being first
proposed by R. Shaker (transnasal pharyngoesopha-
geal gastroduodenoscopy (TEGD) [2]. Later Hermann
and Recio first performed the procedure adding tests
with bolus (functional pharynoesophagoscopy) [3].
With shorter instruments, and where the study of the
stomach or duodenum is not required, a transnasal
examination of the oesophagus is possible (Transnasal
has also been used for many years in the instrumental
evaluation of patients with ENT complaints [4]. In a
short time, it became an office practice performed on
outpatients without anaesthesia. Several protocols
have been proposed [2,5,6] for patients with bolus
sensation or other complaints of GERD, as previously
mentioned. More recently the possibility of directly
evaluating and testing with bolus the oesophageal
phase of swallowing with endoscopes (oesophageal
FEES, E-FEES), in the context of an endoscopic evalu-
ation of swallowing has been re-proposed [7].
With these premises, the aims of this paper are: (1)
to define the main steps of the procedure, (2) to
ascertain its safety, (3) to define the main implications
in its use and implementation in a daily phoniat-
ric setting.
The procedure and the clinical cases
In our Swallowing Center, patients with a possible
low dysphagia are selected for an E-FEES after a

CONTACT Daniele Farneti lele.doc@libero.it AUSL della Romagna, Infermi Hospital, Servizio di Audiologia Foniatria, Via Settembrini n. 2, 47921
Rimini (RN), Italy.
ß 2019 International Association of Physicians in Audiology
198 D. FARNETI AND E. GENOVESE

Table 1. The main steps of the anatomo-functional evaluation of upper aero-digestive tract.
Static evaluation Dynamic evaluation Sensation
Endoscope position
NASAL-RHINOPHARYNGEAL (naso- Morphology of: Speech General of the area:
rhino-pharynx) - nasal cavities Velo-pharyngeal sphincter : - reaction to the endoscope
- rhinopharynx - Velum deviation - reaction to light touch of structures
- pathological muscular activities - Gap of closure Pooling
Pooling site: - /s/ forced - perception
. nasal cavities Deglutition - cleaning efforts
. rhynopharynx - nasal regurgitation - cleaning effectiveness
. tubal ostium

HIGH (meso-pharynx) Morphology of: Speech General of the area:

- base of tongue - base of tongue: retraction - reaction to the endoscope
- pharyngeal wall . /l/ ball - reaction to light touch of structures
- pathological muscular activities . /k/ cocco - gag reflex (base of tongue)
Pooling site: - Pharyngeal wall deviation: Pooling
. valleculae . /e/ strained - perception
. pyriform synus . /e/ repeated - cleaning efforts
. post-pharyngeal wall Deglutition (dry swallowing) - cleaning effectiveness
. retro-cricoidal space - Base of tongue movements
- Pharyngeal movements

ANTERIOR (retrograde) (oral cavity) Morphology of: Speech General of the area:
- tip, medium and base of tongue - tongue movements: - reaction to the endoscope
- hard palate and gums/teeth . /ka/ repeated - reaction to light touch of structures
- lips - lips movements : - gag reflex (tongue)
Pooling site: . /pa/ repeated Pooling
. hard palate Deglutition (dry swallowing) - perception
. tongue: tip, medium, base - medium, base of - cleaning efforts
tongue movements - cleaning effectiveness

ANTERIOR POSTERIOR (oral cavity) Morphology of: Speech General of the area:
- base of tongue - tongue movements: - reaction to the endoscope
- soft palate (superior face) . ka/ repeated - reaction to light touch of structures
- glosso-palatal seal - palate movements - gag reflex (tongue)
- coana . /ma/ repeated Pooling
Pooling site: Deglutition (dry swallowing) - perception
. hard palate - tongue movements - cleaning efforts
. tongue: body, base - palate movements - cleaning effectiveness
- pharyngeal movements

LOW (hypo-pharynx) Morphology of Speech General of the area:

- hypo-pharynx - Glottic closure: - reaction to the endoscope
- larynx during respiration . /a/ strained - reaction to light touch of:
- pathological muscular activities . /a/ repeated . aryepiglottic folds
Pooling site: - posterior commissure deviation . arytenoids
. Sopra-glottic . /a/ strained . true vocal folds
. glottic . /a/ repeated . false vocal cords
. sub-glottic - glottic opening: Pooling
. cervical trachea . sniff - perception
- vocal quality - cleaning efforts
Sphincterial activities - cleaning effectiveness
- True vocal cords closure:
/a/ strained (time)
- False vocal cord closure:
. /a/ forced
. glide up /ee/
. Valsalva
. cough
- epiglottis inversion:
. dry swallows

DEEP (oesophagus) Morphology of Sphincterial activities General of the area:

- UES - UES - reaction to the endoscope
- body . Valsalva - reaction to light touch of structures
- LES . cough Pooling
. belching - perception
. dry swallows - cleaning efforts
- LES - cleaning effectiveness
muscular activity
- body
 HEARING, BALANCE AND COMMUNICATION 199

Table 2. Main sensory motor events during the test with bolus.
Phase Sensory-motor event
Bolus tests: different volumes and consistencies

Oral White out

Endoscope in anterior position
Endoscope in anterior-posterior position
Endoscope in high position

Linguo-palatal sphincter competence Spillage (premature bolus falling)

Tongue movements Bolus preparation
Tongue propulsion Bolus propulsion
Oral transport Bolus flow
Total time Site of pharyngeal reflex onset
Pre-swallow penetration
Pre-swallow aspiration

Pharyngeal White out

Endoscope in high and low position

Velo-pharyngeal closure Bolus flow

Vocal cords closure Site of pharyngeal reflex onset
Laryngeal elevation Pre/intra-swallow pwnwtration
Epiglottic inversion Pre/intra-swallow aspiration

Laryngeal returns low Pooling evaluation (site, amount, management):

Epiglottis returns to rest Post-swallow penetration
Post-swallow aspiration
Awareness
Dry swallows
Clearing
Gurgling
Cough with/without emission residues
Effective management (larynx/trachea cleaned)

Oesophageal White out

Endoscope in deep position
Endoscope in deep retrograde position

Peristaltic activity Bolus delivery

Sphincters activity Bolus flow
Bolus pooling
Bolus clearing

previous FEES [8]. The patient is sitting upright in a
chair, facing the clinician. A Pentax 70 cm flexible
endoscope, 3.5 mm diameter is used. Neither pre-
medication, nor topical nasal anaesthesia, nor decon-
gestion is administered.
In our Center, only instrumentation without opera-
tive channels are used, so the patients are previously
informed about the possibility of being referred to a
gastroenterologist for further dynamic or bio-
ptic procedures.
The procedure (Table 1) allows for a direct viewing
of the status and activities of the structures involved
in swallowing. With the tip of the endoscope in the
anterograde position the retro-cricoideal area (space)
is intercepted. The patient is invited to drink a sip of
water, to facilitate the passage of the endoscope into
the oesophagus. This possibility and the resistance
of the UEP against the passage is evaluated.
Subsequently the oesophageal wall and its movements,
spontaneous or transmitted from nearby structures,
are observed. The tip is driven up to the cardias: the
area (anatomy), the status of contraction (physiology)
(cardial incontinence), its content (foam saliva, gas
passage, bile) and its opening (spontaneous or dry
swallow induced) are evaluated. The resistance against
the tip’s passage has to be perceived and considered.
The perception of these activities or a feeling of discom-
fort by the patients are markers of good sensation but
the feeling of pain is a possible threat sign. The func-
tioning of the UEP is, therefore, evaluated. With the tip
of the endoscope in a retrograde position, a direct view-
ing of the sphincter and its activity during different
tasks (dry swallowing, belching, Valsalva) is possible.
During the test with bolus (Table 2) the patient
swallows boluses of different consistency and volume,
as during FEES. With the tip of the endoscope in the
anterograde position, the entrance of the bolus into
the oesophagus is intercepted (oesophageal delivery)
and followed along the cavity (bolus flow: cm/sec)
toward the cardias region. The peristaltic activity of
200 D. FARNETI AND E. GENOVESE

the wall is observed up to the opening of the cardias:
the time between the arrival and the opening (gastric
delivery) is quantified. The possible presence of resi-
dues after delivery is evaluated, as are the time and
effectiveness of their clearing. With the tip of the
endoscope in the retrograde position the entrance of
the bolus into the oesophagus is directly viewed
(oesophageal delivery). The UES opening is consid-
ered after the command of swallowing (timing detec-
tion) and the amount of bolus passed through is
likewise evaluated (semi-quantitative volume detec-
tion). Table 3 summarizes the main steps of E-FEES.
Finally the procedure allows for the proper place-
ment of catheters before functional pharyngeal or
oesophageal assessment or for therapeutic proce-
dures [9].
Patients and methods
From 437 consecutive outpatients, seen in our
Swalloing Center from August to December 2011, 71
patients who had undergone TNE were initially
selected for a retrospective analysis. All these patients
complained of voice disorders (voice fatigue, breaks,
hoarseness), excessive throat clearing, globus, episodes
of coughing when drinking or eating. All these patients
had previously undergone a FEES evaluation [8].
Twenty patients (13M/7F, range 19–78 years, mean age
50, 51 years) were selected based on a reflux finding
score (RFS) > 7 [10] and a reflux symptom index
(RSI > 13) [11]. Smokers, alcoholics, patients with
neurological, gastroenterological pathologies or acute/
chronic rhinosinusitis were excluded. Table 4 summa-
rizes the characteristics of the patients selected.
The following FEES alterations of swallowing were
considered: premature spillage, delay in swallowing
reflex, penetration, aspiration, residues. Airway inva-
sion was quantified with the penetration aspiration
scale [12] and residues with the pooling score
(p-score) [13,14]. The oesophageal alterations were
described with the Los Angeles classification [15].
Results
Mean RSI was 16.3 and mean RFS was 9.8. At FEES
no aspiration was documented but only 5 episodes of
penetration (PAS 2–5). Pre-swallow alterations (spill-
age, delay in swallowing reflex) were documented in 7
patients and residues in 9 patients.
The p-score documented mainly low-moderate
severity grade of dysphagia.
The main E-FEES findings were: 10 esophagitis (3
minimum alterations and low severity at the modified
Los Angeles classification, 1 gastroesophageal junction
incontinence, 2 hiatal hernia, 4 motility alterations, 2
diverticula, 1 carcinoma.

Table 3. The main steps of E-FEES.

Endoscope position DEEP
Evaluation Tip anterograde Tip retrograde
Anatomo-functional Retrocricoideal space interception
Sensation UES area: Activity in dry swallowing, belching, Valsalva
morphological evaluation
UES passing: resistance against the tip’ passage
Body:
in depth progression
oesophageal wall morphology
esophageal wall movement: spontaneous, transmitted
LES area:
morphological evaluation
status of contraction (continence)
content: foam saliva, gas passage, bile
opening: spontaneous or dry swallow’ induced
LES passing: resistance against the tip’ passage Gastroesophageal junction, cardia
Test with bolus UES area Bolus entrance (delivery)(timing)(volume)
Body: Peristaltic activity
Bolus entrance
Bolus flow Bolus flow
Bolus delivery
LES area:
opening
residues
clearing : effectiveness (timing) Gastric delivery
 HEARING, BALANCE AND COMMUNICATION 201

Table 4. Case series and main instrumental findings.

Pts Sex Age FEES findings E-FEES findings
1 F 19 Spillage (p-s 4) None
2 F 38 Spillage (p-s 4) Esophagitis (LA A)
3 F 54 Pooling (p-s 6) Hiatal hernia
4 F 44 Pooling (p-s 7) Esophagitis (LA A)
5 F 62 Penetretion (p-s 7) Diverticula
6 F 33 Spillage (p-s 8) Esophagitis (LA A)
7 F 78 Penetration (p-s 9) Carcinoma
8 M 49 Pooling (p-s 4) Hiatal hernia
9 M 33 Pooling (p-s 6) Esophagitis (LA A)
10 M 37 Spillage (p-s 4) None
11 M 78 Pooling (p-s 6) Motility alterations
12 M 35 Spillage (p-s 6) Esophagitis (LA A)
13 M 75 Penetration (p-s 7) Motility alteration
14 M 41 Pooling (p-s 4) None
15 M 42 Penetration (p-s 5) Esophagitis (LA B)
16 M 68 Spillage (p-s 6) Gastroesophageal junction incontinence
17 M 70 Pooling (p-s 7) Motility alterations
18 M 37 Pooling (p-s 4) Esophagitis (LA A)
19 M 61 Spillage (p-s 7) Motility alteration
20 M 58 Pooling þ Penetration (p-s 9) Diverticula
(LA: modified Los Angeles classification) (p-s: p-score).
Main E-FEES findings:
7 esophagitis (3 minimum alterations).
1 gastroesophageal junction incontinence.
2 hiatal hernia.
4 motility alterations.
2 diverticula.
1 carcinoma.
Main FEES fidings:
5 spillage.
9 residues.
5 penetration.
p-score.
mainly low severity grade of dysphagia.

Table 4 summarizes the main functional and
pathological reliefs of the selected sample.
Discussion and conclusion
Oesophageal alterations are not rare in patients with
deglutition disorders, likewise voice alterations are
frequent signs of a GERD or LPR. In our sample, no
gastroesophageal pathologies were known although
the clinical history and the RSI and RFS were strongly
suggestive of a lower involvement of the upper aero-
digestive tract. The correlation with deglutition disor-
ders was less characteristic, with the finding of more
morphological than functional alterations of the
oesophagus (only 4 motility alterations were found,
mainly in the elderly patients), involving mainly low
severe inflammatory diseases (Table 4). The elderly
patient with carcinoma had a particular complaint of
severe hypokinetic dysphonia, linked to a slow but
progressive decline of her general health condition.
She also complained of dyspepsia and chest pain, so
she should have been excluded from the sample.
However, it was decided to perform E-FEES in an
attempt to explain the complex symptomatology.
In our limited experience, the recurrence of voice
and deglutition complaints, due to an increased
involvement of the larynx during pathologies of the
upper digestive tract, is extremely high. Sometimes
the oesophageal condition does not explain the
involvement of the larynx or the subjective perception
of voice quality.
The aim of our work, apart from the correlation
between voice and gastroesophageal complaints (not
yet adequately investigated, at this time), underlines
the feasibility of the E-FEES procedure which gives
immediate morphological and functional information
about the oesophageal status. No side effects or com-
plications occurred and the procedure was well toler-
ated by all the patients: it takes about 15–20 min to
be performed. Finally, with a previous explanation, all
the patients accepted the procedure and the possibility
of being referred to the gastroenterologist for a subse-
quent conventional endoscopic examination.
The high correlation with voice and deglutition
disorders complained of by patients with gastroeso-
phageal pathologies requires an instrumental tool able
to give information about the oesophageal status in
real time. So the possibility of including the E-FEES
in a phoniatric setting has to be strongly considered
202 D. FARNETI AND E. GENOVESE
in daily practice. In this case, the diagnostic possibil-
ities of E-FEES require a standardization of the exam-
ination in the field of endoscopic procedures. In our
early experience, E-FEES has been a safe, reliable and
a cost-effective technique, useful in the evaluation of
the esophageal phase of swallowing, with the intent of
clarifying the correlation with oropharyngeal dyspha-
gia and laryngeal involvement in LPR and GERD.
Disclosure statement
No potential conflict of interest was reported
the authors.
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