FEES vs. MBS: When a Bedside Swallow Study Is the Right Tool for Older Adults

3 days ago

7 min read

What is a FEES study?

A FEES — Fiberoptic Endoscopic Evaluation of Swallowing — is a bedside swallow study performed by a speech-language pathologist using a thin, flexible scope passed through the nose to watch the throat in real time as you swallow real food and liquids. It does not use X-rays, barium, or contrast dye. It can be done at the bedside in a hospital, skilled nursing facility, assisted living community, or in the home — there is no need to transport a medically fragile patient to a hospital radiology suite.

FEES has been a clinically validated instrumental swallowing assessment since the 1980s and can provide similar findings to the Modified Barium Swallow Study (MBSS) for most diagnostic questions. For some questions — particularly those involving secretions, vocal fold function, fatigue across a meal, and real-food trials — FEES is the better tool.

What is the difference between FEES and MBS?

The Modified Barium Swallow Study (MBSS), sometimes called a videofluoroscopic swallowing study (VFSS), uses X-rays to watch a column of barium-coated food and liquid travel through the mouth and throat. It is performed in a radiology suite. The Fiberoptic Endoscopic Evaluation of Swallowing (FEES) uses a small flexible camera passed through the nose to directly visualize the throat and vocal folds as the patient swallows actual food and liquid.

Both tests are valid. They answer slightly different questions, and a Board Certified Specialist in Swallowing and Swallowing Disorders (BCS-S) is trained to recommend the right one for each clinical situation.

Here is the side-by-side:

What it looks at	MBSS (X-ray based)	FEES (camera based)
Secretions and saliva	Not visible	Directly visible at rest
Vocal folds and voice box	Indirect (side view only)	Direct, color visualization
Real food and drink	Barium-coated only	Actual food and liquid from the facility or home
Time limit per study	2-3 minutes of X-ray time	A full snack or partial meal
Strategy testing	Limited by radiation exposure	Unlimited — test, modify, retest in one session
Radiation exposure	Yes	None
Setting	Hospital radiology suite	Bedside (home, facility, or hospital room)
Repeat assessment	Rare due to radiation and transport	Easy — re-scope in 1-2 weeks to verify the plan works
Patient transport needed	Yes	No

When is FEES the right choice?

A FEES study is the right choice when the clinical question involves any of the following:

1. Concerns about secretions or silent aspiration. Many older adults — especially after a stroke, with Parkinson's disease, with head and neck cancer, with advanced dementia, or after a long hospital stay — pool saliva in their throat without coughing. This is called silent aspiration of secretions and is a leading cause of aspiration pneumonia in seniors. FEES is the only instrumental study that can see secretions directly, because MBSS only shows what the barium coats. (American Speech-Language-Hearing Association)

2. Voice changes, wet vocal quality, or recent intubation. FEES directly visualizes the vocal folds, allowing the speech pathologist to assess for vocal fold paresis

3. Fatigue across a meal. A 2-3 minute X-ray window cannot capture the moment late in a meal when a tired patient begins aspirating. FEES can run through a full snack or partial meal at the bedside, which is when most real-world aspiration actually happens.

4. Patients who cannot safely travel to a hospital. Patients with advanced dementia, behavioral fragility, severe medical complexity, transport-related pain, or end-of-life considerations often cannot or should not be transported for a radiology study. Bedside FEES brings the instrumental assessment to them.

5. Recurrent pneumonia despite a "safe" MBSS. When the bedside picture and a prior fluoroscopic study disagree, FEES often reveals secretion-driven aspiration that was outside the X-ray field of view.

6. Decisions about diet advancement before discharge. Same-day documentation of safe consistencies and effective strategies — ready for the discharge plan and the care team meeting.

7. Verifying a treatment plan is working. FEES can be repeated in 7-14 days after the speech pathologist has implemented strategies and diet changes. MBSS is typically one-and-done because of radiation and transport burden.

What happens during a FEES study?

A FEES study takes 20 to 30 minutes. The speech-language pathologist begins by gently passing a thin, flexible scope through one nostril until the tip rests just above the throat. The patient is seated comfortably — in their own bed, recliner, or chair. A small amount of topical anesthetic may be used in the nose if desired, though many patients do not need it.

Once the scope is in place, the speech pathologist watches the throat at rest, looking at:

Vocal fold movement and symmetry
Sensation in the throat
Any pooling of saliva or secretions
The general condition of the throat tissue

Then the patient is offered different consistencies of food and liquid — usually starting with what they are currently eating. Common trials include thin liquid, slightly thick liquid, applesauce, pudding, soft solid, and a regular solid. The speech pathologist watches each swallow in real time and tests compensatory strategies — like a chin tuck, head turn, or effortful swallow — to see what helps.

The patient is awake, alert, and able to talk to the clinician throughout. Most patients tolerate FEES very well. Side effects are uncommon — occasional mild nosebleed, sneezing, or watery eye.

Is FEES safe for older adults?

Yes. FEES has an excellent safety profile, including in medically fragile patients. A 2020 systematic review reported the overall complication rate as well under 1%, with the most common findings being mild epistaxis (nosebleed), sneezing, or vasovagal symptoms — all self-limited. (PubMed Central: Best Practices in Instrumental Swallowing Assessment)

Specifically, FEES is appropriate for:

Patients on blood thinners (with standard precautions)
Patients with cognitive impairment, including advanced dementia
Patients with cardiac or pulmonary fragility
Patients in hospice or comfort-focused care, where transport is not appropriate
Patients who have recently been extubated or decannulated
Patients with a tracheostomy in place

FEES is generally avoided when a patient has a recent severe nosebleed, an unstable airway requiring monitoring not available at the bedside, or significant agitation that prevents safe scope placement.

Does FEES require a doctor's referral?

In Ohio, an instrumental swallowing assessment like FEES is typically initiated by a physician's order. In skilled nursing and assisted living settings, the order is usually entered by the attending physician, medical director, or nurse practitioner after the in-house speech-language pathologist or nursing team flags a clinical concern. Patients and families can ask their physician about a FEES referral when transport to a hospital for an MBSS is not realistic, or when the clinical picture involves secretions, voice changes, or recurrent pneumonia.

REN Integrated Therapies works with referring physicians, case managers, and facility SLP teams to make the order and scheduling process straightforward.

How is FEES different from a barium swallow?

A barium swallow is a different test entirely. A standard barium swallow uses X-rays to look at how barium moves from the mouth all the way down through the esophagus into the stomach — it is primarily an esophageal study, often used to evaluate reflux, narrowing, or motility issues in the esophagus. A modified barium swallow study (MBSS) uses X-rays to focus on the oral and pharyngeal phases of swallowing — the mouth and throat. A FEES uses a camera to look at the throat directly. FEES and MBSS evaluate the same anatomical area; a standard barium swallow looks lower, in the esophagus.

Where can I get a FEES study in Columbus, Ohio?

REN Integrated Therapies provides mobile bedside FEES across central Ohio — Powell, Columbus, Dublin, Worthington, Westerville, Delaware, Lewis Center, Hilliard, Upper Arlington, and surrounding communities. Studies are performed at the bedside in skilled nursing facilities, assisted living communities, and private homes on a case-by-case basis by Dr. Veena Kallambettu, CCC-SLP, BCS-S, a Board Certified Specialist in Swallowing and Swallowing Disorders.

For facilities, REN offers a flat-rate per-study contract structure. For physicians and families considering a FEES referral, the practice can be reached at 614-350-0415 or info@rentherapies.com.

Frequently asked questions

Q: Is FEES painful?

FEES is not painful for most patients. The scope is thin and flexible, and a topical anesthetic can be used in the nose if desired. The most common sensations are a brief tickle, watery eye, or urge to sneeze when the scope is first passed.

Q: How long does a FEES study take?

A typical FEES study takes 20-30 minutes from start to finish, including the scope placement, the food and liquid trials, and the strategy testing.

Q: Does insurance cover FEES?

Medicare Part B, Medicare Advantage, Medicaid, and most commercial insurance plans cover medically necessary FEES studies (CPT 92612). Coverage details depend on the setting and the patient's plan. In skilled nursing settings during a Medicare Part A stay, the study is covered through the facility's per-diem reimbursement under Medicare's consolidated billing rules.

Q: How is a FEES study different from a clinical (bedside) swallow evaluation?

A clinical swallow evaluation is a non-instrumental assessment — the speech pathologist watches the patient swallow, listens for changes in vocal quality, and checks for outward signs of trouble. It is a valuable screening tool but cannot see inside the throat. A FEES is an instrumental study — the speech pathologist directly visualizes the throat with a camera. FEES is recommended when the clinical evaluation suggests aspiration risk and a definitive instrumental study is needed to guide diet and treatment.

Q: Can FEES be repeated?

Yes. One of the advantages of FEES is that it can be repeated as the patient's condition changes — typically 7-14 days after a strategy or diet change, to verify the plan is working. MBSS is more difficult to repeat because of radiation exposure and the burden of transport to a radiology suite.

Q: Can FEES be done in the home?

Yes. REN Integrated Therapies provides mobile FEES in private homes across central Ohio for patients who cannot or should not travel to a clinic or hospital. The setup takes about 5 minutes and the study can be performed in a comfortable chair or hospital bed in the home.

Q: Who performs a FEES study?

A FEES study is performed by a speech-language pathologist (SLP) who has completed advanced training in endoscopic instrumentation, swallowing physiology, and clinical interpretation. A Board Certified Specialist in Swallowing and Swallowing Disorders (BCS-S) holds an additional certification reflecting expertise in adult dysphagia assessment, including FEES.

Author

About the author. Dr. Veena Kallambettu is a doctoral-trained speech-language pathologist and Board Certified Specialist in Swallowing and Swallowing Disorders (BCS-S) practicing in Powell, Ohio. She owns REN Integrated Therapies, an adult medical speech-language pathology practice providing dysphagia evaluation and treatment, mobile FEES, voice therapy, cognitive-communication therapy, and aphasia therapy across the Columbus metro and statewide via telehealth.