Research Article

Folia Phoniatr Logop Received: December 3, 2018

Accepted: September 3, 2019
DOI: 10.1159/000503132 Published online: October 22, 2019

Exploring Consistency and Variation

in Fibreoptic Endoscopic Evaluation of
Swallowing Practice in Australia
Michelle Cimoli a, b Jennifer Oates a Emma McLaughlin a, c Susan E. Langmore d
a Discipline
of Speech Pathology, School of Allied Health, Human Services and Sport, La Trobe University,
Melbourne, VIC, Australia; b Speech Pathology Department, Austin Health, Heidelberg, VIC, Australia; c Speech
Pathology Department, Castlemaine Health, Castlemaine, VIC, Australia; d Department of Otolaryngology, School of
Medicine, Boston University, Boston, MA, USA

Keywords month. Conclusion: This research represents a benchmark in

Dysphagia · Swallowing · Swallowing disorders · Speech
pathology
Abstract
Background: Fibreoptic endoscopic evaluation of swallow-
ing (FEES) is an imaging technique used by speech-language
pathologists (SLPs) and some other health professionals to
assess swallowing. Objectives: The primary aim was to gain
an insight into FEES practices in Australia by characterising
SLPs who use FEES and identifying areas of consistency and
variation in practice. The secondary aim was to explore fac-
tors associated with variation in practice. Method: Cross-sec-
tional survey methodology was used. The link to a web-
based survey was e-mailed to 351 SLPs who practised in
adult dysphagia. Results: The participation rate for the study
was 18.8% (n = 66). Twenty-two SLPs (38.6%) used FEES.
These SLPs represented a cross-section of workplace set-
tings, caseloads, clinical and training experiences. Consis-
tency and variation in FEES procedural and assessment prac-
tices were identified. Some procedural aspects of FEES var-
ied according to whether a medical practitioner was present,
type of FEES training, and number of FEES conducted per
the knowledge of how FEES is used in Australia. Despite the
small number of participants, the findings provide a founda-
tion from which future research questions can be generated.
More extensive examination of the use of FEES by SLPs is
warranted. Further research is also required to establish
methods for attaining and maintaining competency and to
achieve consensus on which aspects of swallowing are as-
sessed when using FEES and how the examination should be
conducted. © 2019 S. Karger AG, Basel
Introduction
Prior to the development of fibreoptic endoscopic
evaluation of swallowing (FEES), videofluoroscopic swal-
lowing study (VFSS) was the predominant instrumental
imaging technique used to assess swallowing [1]. While
FEES is now widely accepted as one of the most common
instrumental assessment techniques used by speech-lan-
guage pathologists (SLPs) to assess swallowing [2], there
is limited information to describe how SLPs use FEES in
clinical practice.
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© 2019 S. Karger AG, Basel Michelle Cimoli

Discipline of Speech Pathology, La Trobe University
School of Allied Health, Human Services and Sport, Melbourne Campus
E-Mail karger@karger.com
Health Sciences 1 Building, Melbourne, VIC 3086 (Australia)
www.karger.com/fpl
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E-Mail Michelle.cimoli @ austin.org.au

 Early reports describing which aspects of swallowing
function could be visualised using FEES were cautious in
their claims; the purpose of FEES was constrained to eval-
uating swallowing safety by identifying penetration and
aspiration [1]. FEES has since evolved to become a com-
prehensive assessment of swallowing function [3]. How-
ever, there is currently no consensus regarding which as-
pects of swallowing should be assessed [4] and which ex-
amination/procedural tasks should be included [5, 6].
FEES equipment is portable and can be used in a vari-
ety of clinical settings and with a range of patient popula-
tions [3]. Early reports of FEES described its use in out-
patient and inpatient settings [1] with a range of patient
populations including stroke, head and neck cancer, re-
spiratory disorders, and others [7, 8]. There are also re-
ports of FEES being used in residential care facilities [9].
While there is no universally established staffing mod-
el for FEES to describe which staff are involved and their
roles and responsibilities, current professional practice
documents indicate that SLPs may conduct FEES within
an SLP-led model [10–12]. In this model, an SLP is re-
sponsible for performing all aspects of a FEES assessment,
including the insertion and operation of the endoscope
[13]. While the clinical and financial benefits of SLP-led
models for FEES have been described [13], how widely
this model has been adopted is not yet known.
Many professional associations representing SLPs
consider FEES an advanced or specialised area of practice
[10–12]. SLPs are expected to participate in additional
training beyond entry level (i.e., university degree provid-
ing a qualification to practise as an SLP) in order to be-
come competent in FEES [10–12, 14, 15]. While various
professional associations representing SLPs provide rec-
ommendations for training [10–12, 14, 15], these recom-
mendations vary in the methods, content, and structure
of the training proposed.
Given the expansion of FEES, it is important to under-
stand how it is used in practice. Research indicates that SLPs
in the UK, Republic of Ireland, Canada, and the USA use
FEES [16–21]. However, there are limited data to describe
its use in other countries such as Australia. The primary aim
of the present study was to gain an insight into FEES prac-
tices in Australia by (a) characterising the SLPs who use
FEES in regard to their clinical and training experiences, (b)
identifying consistency and variation in the examination
procedures for conducting FEES including procedural ap-
proaches and staff involved, and (c) identifying consistency
and variation in which aspects of swallowing are assessed
using FEES. The secondary aim of the study was to explore
factors that may contribute to variation in practice.
2 Folia Phoniatr Logop
DOI: 10.1159/000503132
Materials and Methods
The present study represents the first study in a two-part re-
search project investigating the use of instrumental swallowing as-
sessments by SLPs (the second part of the research focussed on
VFSS practices). The aims of the research were addressed through
a cross-sectional design using survey methodology. The Faculty
Human Ethics Committee of La Trobe University, Faculty of
Health Sciences (Project No.: FHEC11/159), approved the study.
SLPs were recruited to the study if they were: (1) current members
of Speech Pathology Australia (SPA)1, (2) working in Australia in
the area of adult dysphagia, and (3) using VFSS and/or FEES in
clinical practice.
Survey Development and Administration
The general principles of survey design [22] guided the authors
in their development of a new survey. The survey was designed to
address the aims for part 1 and part 2 of the research. Data describ-
ing VFSS practices will be analysed and reported in a future paper.
Figure 1 illustrates the conceptual framework for the survey, which
reveals the key domains for investigation and major topics within
each domain. The key domains included: “clinical experience,”
“FEES practice,” and “VFSS practice.” The major topics addressed
within each domain were “experience,” “procedures,” and “assess-
ment.” The “experience” topic related to years of experience, fre-
quency of practice, and training. The authors conceptualised the
“assessment” domain as comprising three elements: anatomy, bio-
mechanics, and function (with reference to a bolus [saliva, fluids,
foods]). Methods of assessment, including analysis and reporting,
were also considered elements of the “assessment” domain. The
“procedures” domain related to staff involved, procedural ele-
ments included in the examination, and the procedural approach-
es. The authors specified three types of procedural approaches: (1)
patient-specific approach – the procedure is tailored to each indi-
vidual patient and is modified according to their current status and
findings from the Clinical Swallowing Examination and perfor-
mance throughout the examination; decisions are made in real
time throughout the examination to determine what textures to
present to the patient; (2) protocol-driven examination – strict ad-
herence to a protocol where each patient is trialled with specified
types/consistencies of food and fluids, set amounts/volumes and
number of trials, and a specified sequence for the presentation/
delivery of food and fluid trials; and (3) modified examination pro-
tocol – examination starts in accordance with a protocol and is
modified as appropriate according to patient performance. These
three procedural approaches were identified by reviewing other
authors’ descriptions of examination procedures and protocols for
FEES and VFSS [23, 24].
The survey comprised 200 questions (10 questions relating to
“Clinical experience,” 97 questions relating to “FEES practice,”
and 93 questions relating to “VFSS practice” (refer to the Appen-
dix). A range of question types was used (e.g., single numerical
response, yes/no questions, multiple-choice questions). A 4-point
response option (“usually or always,” “often,” “sometimes,” “nev-
er”) was included for questions that collected data about consis-
tency of practice (e.g., how often different aspects of swallowing
1
Speech Pathology Australia is the peak body that represents SLPs in Aus-
tralia.
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• Duration of general
who use FEES, workplace
experience
Characteristics of SLPs
settings, and patient
• Duration of
dysphagia
populations
experience
• Use of instrumental
assessments
• Clinical caseload
• Workplace
characteristics
Fig. 1. Conceptual framework for survey.
were assessed). Each question included a text box allowing par-
ticipants to volunteer additional information.
The survey underwent pretesting and pilot testing before data
collection began. The authors pretested the survey by reading
through each question and corresponding response options. Mi-
nor changes were made to improve the readability and interpreta-
tion of questions. Following pretesting, the survey was formatted
as a web-based survey and pilot tested. Three SLPs participated in
pilot testing of the web-based survey. These SLPs worked in the
area of adult dysphagia at three different health care facilities in
Melbourne, Australia, and used FEES and/or VFSS in their clinical
practice. Pilot testing identified minor issues with readability and
the layout of the survey that were addressed by reformatting and
editing the survey. Pilot testing revealed that the entire survey
could be completed within 30 min.
Data Collection
A modified version of the Dillman approach [25] was used to
recruit participants. This comprised three points of contact with
potential participants: (1) a notice about the study was posted on
the SPA website; (2) two weeks later, staff from the SPA National
Office Membership Department sent e-mail invitations (including
the link to the web-based survey) to individuals who indicated on
their SPA membership profile that they practised in the area of
adult dysphagia (n = 351); (3) a final e-mail invitation was sent to
the same potential participants 7 days after the first e-mail invita-
tion.
Consent to participate in the study was implied if an individu-
al proceeded beyond the front page of the survey which described
the purpose, methods, demands, and possible outcomes of the
project (including the likelihood and form of publication of re-
sults). Potential participants were not offered any financial reward
or incentives. Participation was anonymous; the Internet Protocol
addresses from which participants accessed the survey were not
recorded. The survey was open for 3 weeks.
Data Analysis
The survey generated nominal (dichotomous and polychoto-
mous), ordinal, and interval data. Data were entered into a Micro-
soft Excel spreadsheet and exported to Statistics v.18 (D3 SPSS
Inc., 2009, Chicago, IL, USA, www.spss.com) for analysis. Descrip-
FEES Practice
• Frequency of
practice
Experience
• Training experiences
FEES practice
• Procedural
approaches
Procedures
• Procedural elements
• Staff involved
VFSS practice
Anatomy • Assessment items
• Analysis methods
Assessment Biomechanics
• Reporting formats
Function
tive statistics were used to summarise the data. For questions that
examined the consistency of practice using the 4-point response
option (“usually or always,” “often,” “sometimes,” and “never”),
the percentage of responses for each option was calculated. Re-
sponses were classified as “highly consistent” if at least 75% of par-
ticipants provided the same response, “moderately consistent” if
50–74% provided the same response, and “inconsistent” if fewer
than 50% of participants provided the same response [26]. Both
the mean and median were used as measures of central tendency
due to the small sample size [27]. Data from the entire sample were
analysed to describe the workplace settings, caseloads, clinical and
training experiences of SLPs who used instrumental swallowing
assessments, and to identify the subgroup of SLPs who used FEES.
Data from the subgroup of SLPs who used FEES were described
and analysed to describe FEES practices, and clinical and training
experiences.
Results
The participation rate for the study was 18.8% (n = 66).
Two surveys were excluded from analysis because the
participants indicated they were not currently practising
in the area of adult dysphagia; a further 7 surveys were
excluded because the participants did not use FEES or
VFSS. The response rates for individual survey questions
varied; these response rates are reported in the tables of
results. Data from 57 surveys were summarised to de-
scribe the characteristics of SLPs working in adult dys-
phagia who used FEES and/or VFSS. A subgroup of 22
SLPs (38.6%) who used FEES was identified, and their
data were used to analyse FEES practice. Fewer SLPs used
FEES (n = 22) compared to VFSS (n = 57). SLPs who used
FEES also used VFSS. None of the participants in the
present study solely used FEES.
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 SLPs Who Use FEES – Clinical Experience, Table 1. Proportion of SLPs (%, n) who “usually/always” assess
Training Experience, Workplace Settings, and Patient anatomy items using FEES
Populations
Item Symmetry General appear-
All SLPs who used FEES self-identified as dysphagia ance (size, shape)
specialists. The mean number of years of experience prac-
tising as an SLP was 15.2 (SD = 8.3; median = 14.0, Mucosal condition n.a. 82.4 (14)
IQR = 6.5–23.0) with a range of 3.0–33.0. The mean num- Nasal cavity 17.6 (3) 23.5 (4)
ber of years practising in the area of adult dysphagia was Soft palate 52.9 (9) 47.1 (8)
Base of tongue 50.0 (8) 47.1 (8)
14.7 (SD = 8.1; median = 14.0, IQR = 6.5–20.5) with a Valleculae 64.7 (11) 70.6 (12)
range of 3.0–33.0. The mean percentage of working time Epiglottis 41.2 (7) 64.7 (11)
dedicated to dysphagia was 72.9 (SD = 18.2; median = Pharynx 64.7 (11) 70.6 (12)
80.0, IQR = 65.0–89.0) with a range of 30.0–100. The mean Pharyngeal constrictors/walls 52.9 (9) 58.8 (10)
number of years of experience using FEES (participants Lateral channels 47.1 (8) 64.7 (11)
Piriform fossae 58.8 (10) 64.7 (11)
were asked to estimate to the nearest whole number) was Larynx 70.6 (12) 70.6 (12)
6.6 (SD = 4.2; Median 6.0 [IQR = 4.0–10.0]) with a range Aryepiglottic folds 64.7 (11) 64.7 (11)
from 1.0 to 15.0. The mean number of FEES conducted in Arytenoids 64.7 (11) 70.6 (12)
a typical month was 3.1 (SD = 3.6; median 1.5, IQR = 0.1– Vocal folds 82.4 (14) 82.4 (14)
5.0) with a range of 0–12. There were 3 SLPs who indi- Ventricular folds 58.8 (10) 64.7 (11)
Subglottic region 23.5 (4) 41.2 (7)
cated that they used FEES but reported they did not rou-
tinely conduct FEES in a typical month. Participants were n.a., not assessed. Italics denote ≥75% of participants “usually/
asked to estimate the percentage of their patients (those always” assess this item. The question relating to “mucosal
for whom the participant is primarily responsible) who condition” differed from the other anatomy items: participants
undergo an instrumental swallowing assessment as part of were asked how often they assessed mucosal condition.
speech-language pathology management. For SLPs who
used FEES, the median was 15.0% [IQR = 5.0–40.0], and
the mean was 25.1% [SD = 24.3]. n = 10). Just over half of the SLPs who use FEES complet-
The majority of SLPs who used FEES undertook most ed “formalised training (e.g., set activities, set hours/
of their dysphagia work in an acute care facility [e.g., number of procedures) with assessment of competency
medical, stroke or intensive care unit] (95.0%, n = 19). included” (52.9%, n = 9); a small number of SLPs com-
One of the participants worked in a subacute care facility pleted “formalised training with no assessment of compe-
(i.e., rehabilitation or community rehabilitation unit). tency included” (23.5%, n = 4).
The majority of SLPs who used FEES worked in publicly
funded facilities (76.2%, n = 16). A smaller proportion FEES Procedures – Staff Present, Protocols, and
worked in privately funded facilities (19.0%, n = 4). One Procedural Elements
SLP worked in both publicly and privately funded facili- Most SLPs usually conducted FEES with another SLP
ties (4.8%). SLPs who used FEES reported their largest (75.0%, n = 15). An otolaryngologist was also usually
dysphagia caseloads as: stroke/neurology/neuroscience present (80.0%, n = 16). Less than half of the SLPs con-
(42.8%, n = 9), mixed clinical populations (47.6%, n = 10), ducted FEES with a nurse (38.9%, n = 7). Less than one
medical oncology (4.8%, n = 1), and traumatic brain in- third of SLPs conducted FEES without the presence of a
jury (4.8%, n = 1). medical practitioner2 (30.0%, n = 6). The involvement of
Almost all SLPs who used FEES (94.1%, n = 16) had other health professionals such as allied health assistants3
completed professional development or training in FEES (5.1%, n = 1) and oncologists (medical practitioner)
beyond entry level. Most SLPs had observed a trained col- (5.9%, n = 1) was less common.
league (82.4%, n = 14), attended one or more practical SLPs were asked to describe which type of examination
workshops (82.4%, n = 14), and completed self-directed approach they used during FEES according to the defini-
study such as readings or online learning activities (88.2%, tions described earlier in this paper. Most SLPs used a
n = 15). Fewer SLPs reported participating in activities
2
such as informal training programmes (29.4%, n = 5) or The term “medical practitioner” is used throughout this paper to refer to
medical doctor; may also refer to surgeon or physician.
presentations at journal clubs/special interest groups 3 Allied health assistants work under the supervision of health professionals

with no real-life patients/no direct patient contact (58.8%, in a variety of therapeutic and procedural activities [28].
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Table 2. Proportion of SLPs (%, n) who
“usually/always” assess biomechanics of Item Range of movement Speed of Precision of
items using FEES (including movement movement
symmetry)

Soft palate 58.8 (10) 35.3 (6) n.a.

Base of tongue 64.7 (11) 41.2 (7) n.a.
Epiglottis 58.8 (10) 47.1 (8) n.a.
Pharyngeal constrictors/walls 64.7 (11) 41.2 (7) n.a.
Larynx 64.7 (11) 52.9 (9) n.a.
Arytenoids 52.9 (9) 35.3 (6) 41.2 (7)
Vocal folds 64.7 (11) 41.2 (7) 52.9 (9)
Ventricular folds 47.1 (8) 35.3 (6) n.a.

n.a., not assessed.

Table 3. Proportion of SLPs who “usually/

always” assess biomechanics of sphincter/ Item Percent (n)
valve/contact point function items using
FEES Lips 11.8 (2)
Velopharyngeal port 41.2 (7)
Base of tongue to posterior pharyngeal wall contact 56.3 (9)
Laryngeal vestibule/additus 76.5 (13)
Glottis (level of true vocal folds) 76.5 (13)
Cricopharyngeus/upper oesophageal sphincter 47.1 (8)

Italics denote ≥75% of participants “usually/always” assessed this item.

patient-specific procedure (80.0%, n = 16). None of the
SLPs utilised a “protocol-driven” procedure. A small
number of SLPs used a “modified examination protocol”
(20.0%, n = 4).
Over half the SLPs (55%, n = 11) recorded audio (i.e.,
patient and clinician dialogue during the examination,
patient responses such as coughing) during FEES. For
procedural elements “usually/always” included in FEES,
the majority of participants included: (1) endoscope in
situ prior to swallow trials to note anatomy and the pres-
ence of any atypical patterns of movement at rest (90.5%);
(2) endoscope in situ prior to swallow trials to note respi-
ration, cough, phonation (95.2%); (3) endoscope in situ
during swallow trials of different types, consistencies, tex-
tures and volumes of foods and fluids (95.0%); (4) endo-
scope position manoeuvred during swallow trials [e.g.,
hypopharyngeal view during swallow and laryngeal view
after swallow] (95.0%); and (5) therapeutic and/or com-
pensatory manoeuvres and strategies trialled (80.0%). A
smaller proportion of SLPs (38.5%) included “testing of
sensation” in a FEES procedure.
FEES Assessment – Anatomy, Biomechanics,
Function, Analysis, and Reporting
Tables 1–4 summarise the results describing which
items SLPs “usually/always” assessed when using FEES.
SLPs were highly consistent (i.e., “usually/always” assessed
by >75% of SLPs) in assessing 57.1% of the function items.
The function items assessed with high consistency includ-
ed: 100% of all secretion/secretion management items (6/6);
83.3% of the airway protection items (5/6); 55.6% of the
pharyngeal events, clearance, and residue items (5/9). SLPs
varied in their assessment of anatomy, biomechanics, and
biomechanics of sphincter/valve/contact points: 9.7% of
anatomy items (3/31), 8.3% of biomechanics items (2/24),
and 33.3% of the items relating to the biomechanics of
sphincter/valve/contact point functions (2/6) were “usual-
ly/always” assessed by at least 75% of SLPs who used FEES.
Less than 30% of participants (29.4%, n = 5) “usually or
always” analysed FEES recordings frame by frame. The
most common method for reporting results for FEES was
a “combination of text and checklist/rating/scoring form/
template” (60.0%, n = 12). Other methods of reporting in-
cluded: “text-based report form/template (set structure of
areas for comment)” (20.0%, n = 4); “checklist/rating/
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 Table 4. Proportion of SLPs who “usually/always” assess bolus-related (saliva, fluids, foods) function items using
FEES

Items Percent (n)

Secretions/secretion management
Secretions 100.0 (17)
Secretion colour 76.5 (13)
Secretion viscosity 82.4 (14)
Location of pooled secretions 94.1 (16)
Amount of pooled secretions 94.1 (16)
Response to presence of secretions 94.1 (16)
Oral transfer and control
Lip seal 11.8 (2)
Anterior leakage 17.6 (3)
Oral preparation (mastication and bolus formation) 11.8 (2)
Oral control (holding bolus in oral cavity during preparation) 23.5 (4)
Premature spillage 64.7 (11)
Bolus clearance from the oral cavity 23.5 (4)
Oral transfer (movement of the bolus from the oral cavity to the pharynx) 29.4 (5)
Pharyngeal events, clearance and residue
Timing of swallow onset 70.6 (12)
Bolus clearance and propulsion 82.4 (14)
Path/direction of bolus through pharynx 70.6 (12)
Nasal regurgitation 52.9 (9)
Bolus propulsion and clearance through cricopharyngeus/upper oesophageal sphincter 52.9 (9)
Presence of pharyngeal residue after the swallow 88.2 (15)
Amount of pharyngeal residue after the swallow 88.2 (15)
Location of pharyngeal residue after the swallow 88.2 (15)
Patients’ response to the presence of pharyngeal residue 88.2 (15)
Airway protection
Airway protection 88.2 (15)
Penetration and/or aspiration events 88.2 (15)
Amount of bolus that enters the airway 64.7 (11)
Depth of airway entry of bolus during penetration/aspiration 76.5 (13)
Timing of penetration/aspiration (e.g., before, during, after swallow) 76.5 (13)
Patient’s response to bolus entering airway 88.2 (15)

Italics denote ≥75% of participants “usually/always” assessed this item.

scoring form/template (assign a rating to specified param-
eters)” 5.0% (n = 1); “free text (no set structure or format)”
(15.0%, n = 3). Most SLPs indicated that these report
forms had been developed at their workplaces (81.3%, n =
13). A small proportion of SLPs used forms sourced from
another workplace/colleague (12.5%, n = 2). Only one
participant (6.3%) used a published form/template.
Exploring Variation in FEES Practice Based on
Differences in Training, Frequency of Practice, and
Staff Present
To further explore the variations in practice identified
from the primary analyses, secondary analyses of the data
were completed. These secondary analyses compared as-
sessment and procedural practices between subgroups on
the basis of differences in: training (formalised training
[with assessment of competency or with no formal assess-
ment of competency] or no formalised training); staff
present (medical practitioner present or no medical prac-
titioner); and frequency of practice (“moderate-high fre-
quency of practice” [4 or more FEES per month] and “low
frequency of practice” [less than 4 FEES per month]). The
proportion of function items assessed across the different
subgroups was similar. There were differences in the pro-
portion of anatomy and biomechanics items across the
subgroups. The proportion of anatomy items usually/al-
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Table 5. Comparisons of proportions of SLPs (%) who “usually/always” include procedural elements for FEES based on differences in
training, frequency of practice and staff present

Procedural element Training Frequency of practice Staff present

formal no formal less than 4 4 or more per medical no medical
training training per month month practitioner present practitioner present

Testing of sensation 18.2 50 41.7 20.0 43.8 20.0

Frame-by-frame analysis 36.4 16.7 22.2 40.0 33.3 20.0

Table 6. Comparisons of proportions of SLPs (%) who “usually/always” assess anatomy, biomechanics and function items for FEES based
on differences in training, frequency of practice and staff present

Items Training Frequency of practice Staff present

formal no formal less than 4 4 or more per medical ­ no medical
training training per month month practitioner present practitioner present

Function 57.1 50.0 50.0 60.7 57.1 64.3

Anatomy 29.0 6.5 0 87.1 9.7 32.3
Biomechanics 0 12.5 25.0 0 10.7 0

ways assessed was higher for SLPs who (1) completed for-
malised training, (2) conducted 4 or more FEES per
month, and (3) had no medical practitioner present dur-
ing the examination. The proportion of biomechanics
items assessed was higher for SLPs who (1) had not com-
pleted formalised training, (2) conducted fewer than 4
FEES per month, and (3) conducted the examination with
a medical practitioner present. The use of frame-by-
frame analysis was higher for SLPs who (1) had complet-
ed formalised training, (2) conducted 4 or more FEES per
month, and (3) had a medical practitioner present. Test-
ing of sensation was usually/always included by SLPs who
(1) had not completed formalised training, (2) conducted
fewer than 4 FEES per month, and (3) had a medical prac-
titioner present. Tables 5 and 6 summarise the results.
[3], the participants in this study who used FEES mostly
worked in acute hospital settings, and primarily with
stroke/neurology/neurosciences or a mixed caseload. The
clinical experience and training profiles created through
the data revealed that most SLPs who used FEES self-
identified as dysphagia specialists and have been working
in the area of adult dysphagia for at least 3 years. These
data, combined with the data describing the high propor-
tion of SLPs who completed formalised training (i.e., set
activities, set hours/number of procedures), are consis-
tent with the assertion that FEES is a technique that re-
quires additional training to achieve competency and is
not undertaken by new graduates [29]. However, the
competency standards achieved may vary given that just
over half of the SLPs completed formalised competency
training that included assessment of competency.

Discussion FEES Procedures – Staff Present, Protocols, and

This research provides an insight into how FEES is used
in clinical practice by characterising a cohort of SLPs with
regard to their clinical and training experiences, and by
identifying areas of consistency and variation in practice.
SLPs Who Use FEES – Clinical Experience, Training
Experience, Workplace Settings, and Patient Populations
While research describes the efficacy of using FEES
with a diverse range of populations and clinical settings
Procedural Elements
The majority of SLPs in the present study conducted
FEES using a patient-specific approach; none of the SLPs
in this study conducted FEES using an examination pro-
tocol. When using a patient-specific approach, SLPs vary
the tasks and bolus types based on the performance of the
patient [23, 24]. This approach is problematic because it
potentially affects the validity and reliability of judgments
made; the sources of variation in a patient’s performance
are not controlled [30]. One explanation for these results,
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and the predominance of a patient-specific approach,
may be that SLPs are reluctant to use existing protocols
because the validity of these existing FEES protocols has
not yet been tested. Another explanation is that these re-
sults reflect a philosophical position that characterises
dysphagia practice more broadly. Earlier studies of dys-
phagia practice have reported the prevailing use of a pa-
tient-specific approach when SLPs conduct swallowing
assessments [31–33]. Researchers have suggested that
SLPs perceive a tension between applying measurement
principles to their practices while attempting to satisfy the
objectives of patient-centred care [23, 34, 35]. Further re-
search is needed to evaluate the validity of existing FEES
examination protocols and explore SLP attitudes regard-
ing the use of examination protocols in dysphagia prac-
tice.
The results from the present study revealed that most
SLPs conducted FEES with another SLP present. The
presence of a medical practitioner was also common.
Since FEES was first described, the involvement of a med-
ical practitioner has been discussed and debated [36]. The
predominant staffing model for FEES in the USA and
Canada is an SLP-led model, which does not include a
medical practitioner [10, 17, 20]. There is no legal im-
pediment in Australia to SLPs conducting all aspects of
FEES independently, including inserting and operating
the endoscope [12, 37]. Clinical guidelines and position
statements support the implementation of SLP-led FEES
staffing models [10–12], and the financial benefits and
clinical efficiencies associated with SLP-led models have
also been described [13, 37]. A range of factors is likely to
influence the staffing model adopted for FEES in Austra-
lia. These may include the logistics of accessing equip-
ment and training [37]. Another factor may be the his-
torical perspectives of medical and SLP roles that catego-
rise endoscopy as the domain of medical practitioners
[38].
FEES Assessment – Anatomy, Biomechanics,
Function, Analysis and Reporting
This study identified consistency and variation in
which aspects of swallowing are assessed using FEES. The
majority of SLPs “usually/always” assessed items relating
to airway protection (83.3%). Just over half of the items
relating to pharyngeal events, clearance, and residue were
assessed to a high level of consistency (55.6%). In con-
trast, items relating to “anatomy” and “biomechanics”
were not assessed consistently. Some SLPs in the present
study assessed features and events relating to “oral trans-
fer and clearance” despite not being able to visualise the
8 Folia Phoniatr Logop
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oral cavity. Research supports the accuracy and reliability
of judgments of aspiration and penetration events, and
pharyngeal residue [3, 5, 39–42]. While FEES has the po-
tential to provide useful information about anatomy and
biomechanics [43], the validity and reliability evidence
for many of these items have not yet been examined [3].
The evidence is unclear about whether FEES can be used
to make inferences about events that occur in the oral cav-
ity, and the operational definitions for these surrogate
measures have not yet been proposed.
Most SLPs in the present study assessed secretions, ar-
guably, with a greater level of detail than that supported
by the literature. In addition to assessing location, amount,
and reaction to the presence of secretions, the data from
this study also revealed that SLPs evaluate secretions with
regard to their colour and viscosity. FEES is widely ac-
knowledged to provide the opportunity to visualise secre-
tions in the pharynx and larynx [40, 42, 44, 45]. Studies
have described relationships between the amount and
location of pooled secretions, and patient response to
pooled secretions, to dysphagia, and other health out-
comes such as aspiration pneumonia [3]. Although inves-
tigators have explored how SLPs evaluate the colour of
secretions [44], to the authors’ knowledge, the validity of
judgments of the colour of secretions has not yet been
described.
The present study revealed that the majority of SLPs
documented FEES using locally developed checklists and
text reports to document their findings. Similar to the
problems that arise when using a patient-specific ap-
proach to conduct FEES, the use of locally developed as-
sessment tools may introduce sources of error and bias
that affect the validity and reliability of judgments made
using these tools. To be confident in the judgments made
using these locally developed tools, evidence for the valid-
ity and reliability of these FEES assessment tools is needed.
Exploring Variation in FEES Practice
The findings from the secondary analyses exploring
which factors may be contributing to variation in FEES
practice add to the limited information available on this
topic [6]. Although the results cannot be used to infer
causality, the findings suggest that variation in how SLPs
conducted FEES and which aspects of swallowing they
assessed FEES practice may relate to clinician-related fac-
tors such as staffing models, frequency of practice, and
the type of training SLPs had completed. Given the im-
pact that variation in practice can have on reliability and
accuracy of judgments of swallowing function [46, 47], a
more detailed and robust investigation to identify and, if
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possible, account for and minimise variation in FEES
practice is warranted.
Since FEES was first described in the literature, it has
been compared to VFSS [1]. The results of the present
study revealed that VFSS prevails over FEES as the most
widely used instrumental imaging assessment technique.
In this study, fewer than 40% of SLPs used FEES. Al-
though not a primary aim of this study, the results also
revealed limited utilisation of instrumental swallowing
assessments. Despite the known limitations of the Clini-
cal Swallowing Examination [48, 49], the results of the
present study suggest that the proportion of patients who
undergo instrumental assessments is low. Based on par-
ticipants’ estimates, the average proportion of patients
with dysphagia who undergo instrumental assessments
was less than a quarter. Data from the UK and the USA
indicate that the proportions of patients with dysphagia
who undergo instrumental swallowing assessments var-
ies from 16.7 to 60% [17, 19, 50, 51]. Caution should be
applied when considering the implications of these re-
sults and whether dysphagia practice standards in Aus-
tralia are of concern. However, it is reasonable to question
why SLPs are relying on the Clinical Swallowing Exami-
nation to assess and manage patients with oropharyngeal
dysphagia, and why VFSS continues to be used more
widely than FEES. The decision to undertake an instru-
mental swallowing assessment and the choice of assess-
ment are likely influenced by several factors [26]. The
present findings may provide a rationale for building on
the work describing decision-making and reasoning
when conducting the Clinical Swallowing Examination
[52] and exploring how SLPs make decisions to under-
take instrumental swallowing assessments.
The results describing the frequency of practice for
FEES prompt the need for a more detailed investigation
of how SLPs develop and maintain competency in FEES.
The mean number of FEES conducted in a typical month
(3.1) by the present participants represents a low frequen-
cy of practice according to definitions adopted in research
examining the effects of slow motion review and frequen-
cy of practice on interpretation of VFSS [47]. We applied
the VFSS definitions for frequency of practice to the pres-
ent research because the evidence defining frequency of
practice for FEES is not yet available. While training and
practice standards set by professional organisations and
associations in Europe and the UK imply that competen-
cy is associated with frequency of practice by requiring
specific numbers of FEES be performed to attain compe-
tency and to become a trainer in FEES [14, 15], there is
not yet evidence to verify that these specific numbers of
FEES Practice
procedures are required, or that they are sufficient to at-
tain and maintain competency.
Limitations
The study has several limitations that may affect the
conclusions that can be drawn from the results. The sam-
ple size and participation rate are modest compared to
those reported in earlier survey studies of dysphagia prac-
tice [31, 32, 53, 54]. A number of factors may have ad-
versely affected recruitment to the study and the likeli-
hood of creating a representative sample. One of these
factors may have been the number of questions included
in the survey and the perceived time burden associated
with completing the survey. It is also possible that poten-
tial participants misunderstood the overall aims of the re-
search (i.e., to investigate the use of instrumental assess-
ments – VFSS and FEES), opting not to participate be-
cause they assumed the research to be relevant to SLPs
who used FEES only. Another factor that may have an
impact on the conclusions that can be drawn from the
results is the method of recruitment. While recruiting
participants via SPA enabled us to estimate the popula-
tion size from which our sample was drawn and minimise
notifications and invitations that potential participants
received [25], not all SLPs in Australia who practise in the
area of adult dysphagia who use VFSS and/or FEES had
an equal chance of participating in this research; not all
SLPs in Australia are members of SPA. This may be prob-
lematic and affect the representativeness of the samples,
if practice patterns for members of SLPs differ to those of
non-members of SPA.
Participation in the research was voluntary which may
have introduced self-selection bias. It is possible that
some of the participants were from the same SLP service/
clinic; this may account for higher levels of consistency in
some aspects of practice and affect whether the results can
be generalised to SLPs in Australia who practice in the
area of adult dysphagia and use VFSS and/or FEES.
The differences in the characteristics of the SLPs, fund-
ing models for health care, service delivery, and education
experiences [32] may limit the generalisability of the re-
sults to SLPs in other countries. One further limitation for
this research relates to the method of data collection. Sur-
vey data are vulnerable to the effects of social desirability
[22]. While strategies such as preserving the anonymity
of participants were used as a strategy to minimise this
effect, biases such as these may have influenced the valid-
ity of the data collected.
We also acknowledge the limitations of the survey
methodology to investigate FEES practice, and whether
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these data represent actual clinical practice. Future re- Drafting of manuscript and critical revision – Cimoli, Oates,
search designed to undertake a more detailed examina- McLaughlin, Langmore.
Final approval of version submitted for review – Cimoli, Oates,
tion of practice patterns using methodologies that incor- McLaughlin, Langmore.
porate focus groups, interviews, and observation would
be valuable extensions to the present study.
Appendix

Conclusion Survey Questions

This is the first study to provide data describing con-
sistency and variation in FEES practice in Australia. The
study has provided preliminary insights into FEES prac-
tices among SLPs in Australia and highlighted some fun-
damental issues that could become target areas for future
research and education at least in Australia, if not more
widely. The results suggest that there may be challenges
to implementing FEES in a variety of settings, and that the
utility of FEES with different populations warrants fur-
ther investigation. These findings support the need to de-
velop a valid and reliable assessment and reporting tool
for FEES, and to undertake more detailed research to ex-
amine the influence of factors such as staffing models,
training, and frequency of use on FEES practice.
Statement of Ethics
The Faculty Human Ethics Committee of La Trobe University,
Faculty of Health Sciences (Project No.: FHEC11/159), approved
the study. Consent to participate in the study was implied if an in-
dividual proceeded beyond the front page of the survey which de-
scribed the purpose, methods, demands, and possible outcomes of
the project (including the likelihood and form of publication of
results).
Disclosure Statement
The authors have no conflicts of interest to declare.
Funding Sources
This work was supported by an Australian Government Re-
search Training Program Scholarship.
Author Contributions
Study conception and design – Cimoli, Oates, McLaughlin,
Langmore.
Acquisition, analysis, and interpretation of data – Cimoli,
Oates, McLaughlin, Langmore.
1. Does your current clinical work involve assessing and manag-
ing adults with dysphagia?
2. In what year did you qualify as a speech pathologist?
3. How many years have you been practising as a speech patholo-
gist? (Estimate to the nearest whole number)
4. How many years have you been working with adults who have
dysphagia? (Estimate to the nearest whole number)
5. Estimate the percentage of your current total clinical time that
is dedicated to the assessment and management of adults who
have dysphagia
6. Do you consider yourself to be a dysphagia specialist?
7. Which of the following clinical populations represents the larg-
est proportion of your dysphagia caseload? Tick one response
only
−− Stroke
−− Neurology
−− Ear, nose and throat (ENT), head and neck surgery
−− ENT, head and neck chemotherapy/radiotherapy
−− Respiratory
−− Cardiothoracic
−− Surgical
−− Medical oncology
−− Neurosurgery
−− Mixed (combination of any/all of the above)
−− Other (please specify)
8. In which of the following clinical settings do you undertake
most of your work with adults who have dysphagia? Tick one
response only
−− Acute care facility (e.g., medical unit, stroke unit, intensive care
unit, etc.)
−− Subacute care facility (e.g., rehabilitation, community rehabili-
tation units)
−− Community-based (e.g., community health service, domicil-
lary services)
−− Aged care facility
−− Disability service
−− Mental health service
−− Government
−− Research
−− Education
−− Other (please specify)
9. Is this service privately or publicly funded or both?
10. Thinking about your total current caseload of clients who have
dysphagia (those for whom you are primarily responsible), es-
timate the percentage who have undergone an instrumental
swallowing assessment as part of your speech pathology man-
agement
11. Do you currently use videofluoroscopic swallowing study
(VFSS) when managing people with dysphagia?
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 Questions 12–25 are not included in this version of the survey
because the questions relate to part 2 of the research (to be reported
in a future manuscript).
26. Do you currently use fibre-optic endoscopic evaluation of swal-
lowing (FEES) when managing people with dysphagia?
27. How many years have you been using FEES? (Estimate to the
nearest whole number)
28. How many FEES procedures would you conduct in a typical
month? (Estimate to the nearest whole number)
29. Which personnel are usually present for the procedure? Tick
all that apply
−− Speech pathologist
−− Additional speech pathologist
−− Otolaryngologist/ENT surgeon/head and neck surgeon
−− Gastroenterologist
−− Radiation oncologist
−− Intensivist (intensive care unit physician)
−− Nurse
−− Allied health assistant
30. When using FEES to evaluate swallowing, how often do you
include the following procedural elements? (Response options:
usually or always; often; sometimes; never or rarely):
−− Audio recording
−− Endoscope in situ prior to swallow trials to note anatomy and
the presence of any atypical patterns of movement at rest
−− Endoscope in situ prior to swallow trials to note respiration,
cough, phonation
−− Testing of sensation
−− Endoscope in situ during swallow trials of different types, con-
sistencies, textures and volumes of foods and fluids
−− Endoscopic views during swallow trials including hypopharyn-
geal view during swallow and laryngeal views after swallow
−− Therapeutic and compensatory manoeuvres and strategies tri-
alled
31. A FEES can be conducted as either a protocol-driven or pa-
tient-specific examination
A protocol-driven examination usually requires strict adher-
ence to a protocol specifying that each patient is trialled with the
same specified types/consistencies of food and fluids, the same
specified volumes and number of trials of foods and fluids, the
same specified order and method of presentation/delivery of foods
and fluids (same methods of presentation for each patient). The
same set of procedures are applied for all patients, with all presen-
tations.
A patient-specific approach usually implies that the procedure
is tailored to each individual patient and is modified according to
their current status and findings from the clinical swallowing ex-
amination, and performance throughout the examination. Deci-
sions are made in real time throughout the examination to deter-
mine what textures, volumes to present to patient.
Which of the following statements best describes your ap-
proach?
−− Protocol-driven examination
−− Patient-specific examination
−− Modified protocol – start the examination in accordance with
a protocol and modify as appropriate according to patient per-
formance
32. How do you usually document a FEES?
−− Free text (no set structure or format)
FEES Practice
−− Text-based report form/template (set structure of areas for
comment)
−− Checklist/rating/scoring form/template (assign a rating to
specified parameters)
−− Combination of text and checklist/rating/scoring form/tem-
plate
33. What are the origins of the form you use to document FEES?
−− Locally developed form/template (developed at own work-
place)
−− Sourced from another workplace/colleague
−− Published form/template (Please provide the title and author of
this form)
34. Anatomy – structures and cavities. Thinking about the field of
view obtained via FEES, how often do you evaluate general ap-
pearance and symmetry (at rest) of these anatomical struc-
tures/cavities? (Response options: usually or always; often;
sometimes; never or rarely)
−− Nasal cavity – general appearance (size, shape)
−− Soft palate – symmetry
−− Soft palate – general appearance (size, shape)
−− Base of tongue – symmetry
−− Base of tongue – general appearance (size, shape)
−− Valleculae – symmetry
−− Valleculae – general appearance (size, shape)
−− Epiglottis – symmetry
−− Epiglottis – general appearance (size, shape)
−− Pharynx – symmetry
−− Pharynx – general appearance (size, shape)
−− Pharyngeal constrictors/walls – symmetry
−− Pharyngeal constrictors/walls – general appearance (size,
shape)
−− Lateral channels – symmetry
−− Lateral channels – general appearance (size, shape)
−− Piriform fossae – symmetry
−− Piriform fossae – general appearance (size, shape)
−− Larynx – symmetry
−− Larynx – general appearance (size, shape)
−− Aryepiglottic folds – symmetry
−− Aryepiglottic folds – general appearance (size, shape)
−− Arytenoids – symmetry
−− Arytenoids – general appearance (size, shape)
−− Vocal folds – symmetry
−− Vocal folds – general appearance (size, shape)
−− Ventricular folds – symmetry
−− Ventricular folds – general appearance (size, shape)
−− Subglottic region – symmetry
−− Subglottic region – general appearance (size, shape)
35. When using FEES to assess swallowing function, how often do
you evaluate the following parameters? (Response options:
usually or always; often; sometimes; never or rarely)
−− Soft palate – range of movement including symmetry
−− Soft palate – speed of movement
−− Base of tongue – range of movement including symmetry
−− Base of tongue – speed of movement
−− Epiglottis – range of movement including symmetry
−− Epiglottis – speed of movement
−− Pharyngeal constrictors/walls – range of movement including
symmetry
−− Pharyngeal constrictors/walls – speed of movement
−− Larynx – range of movement including symmetry
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−− Larynx – speed of movement
−− Arytenoids – range of movement including symmetry
−− Arytenoids – speed of movement
−− Arytenoids – precision of movement
−− Vocal folds – range of movement including symmetry
−− Vocal folds – speed of movement
−− Vocal folds – precision of movement
−− Ventricular folds – range of movement including symmetry
−− Ventricular folds – speed of movement
36. How often do you evaluate the condition and appearance of
mucosa as part of your typical FEES? (Response options: usu-
ally or always; often; sometimes; never or rarely)
37. Do you evaluate secretion management as part of your typical
FEES?
38. When using FEES to assess swallowing function, how often do
you evaluate the following attributes/characteristics of secre-
tions and secretion management? (Response options: usually
or always; often; sometimes; never or rarely)
−− Colour
−− Viscosity
−− Location of pooled secretions
−− Amount of pooled secretions
−− Patient’s response to the presence of secretions
39. When using FEES to evaluate swallowing function, how often
do you assess the function of the following sphincters/valves/
contact points? (Response options: usually or always; often;
sometimes; never or rarely)
−− Lips
−− Velopharyngeal port
−− Base of tongue to posterior pharyngeal wall contact
−− Laryngeal vestibule/additus
−− Glottis (level of true vocal folds)
−− Cricopharyngeus/upper oesophageal sphincter
40. When using FEES to assess swallowing function, how often do
you evaluate the following parameters? (Response options:
usually or always; often; sometimes; never or rarely)
−− Anterior leakage
−− Oral preparation (mastication and bolus formation)
−− Oral control (holding bolus in oral cavity during preparation)
−− Premature spillage
−− Bolus clearance from the oral cavity
−− Nasal regurgitation
−− Oral transfer (movement of the bolus from the oral cavity to
the pharynx)
−− Bolus clearance and propulsion through the pharynx
−− Path/direction of bolus through the pharynx
−− Timing of swallow onset
−− Presence of pharyngeal residue after swallow
−− Amount of pharyngeal residue after swallow
−− Location of pharyngeal residue after swallow
−− Patient’s response to the presence of pharyngeal residue
−− Airway protection
−− Penetration and/or aspiration events
−− Amount of bolus that enters the airway
−− Depth of airway entry of the bolus during penetration/aspira-
tion
−− Timing of penetration/aspiration (e.g., before, during, after
swallow)
−− Patient’s response to bolus entering the airway
−− Bolus propulsion and clearance through cricopharyngeus/up-
per oesophageal
sphincter
41. Do you use frame-by-frame analysis of recorded images when
evaluating swallowing using FEES? (Response options: usually
or always; often; sometimes; never or rarely)
42. Not including any education you may have received in your
entry-level university training (qualifying Bachelors or gradu-
ate entry Masters), have you completed any professional devel-
opment or training in FEES?
43. What type of professional development or training in FEES
have you completed? Indicate all that apply
−− Presentation – no real-life patients/no direct patient contact
(e.g., journal club, special interest group presentation)
−− Workshop practical/patient-related activities
−− Observation of trained colleagues
−− Informal training programme
−− Formalised training (e.g., set activities, set hours/number of
procedures) with no formal assessment
−− Formalised training with assessment of competency included
−− Self-directed study (e.g., reading, online learning activities)

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