**3. The endoscopic evaluation**

Since 1988, when Susan Langmore first proposed the FEES protocol [16], the use of endoscopy in the evaluation of swallowing, has become an extraordinary tool in the hand of clinicians, offering a revolutionary way to observe the pharynx and the larynx during dynamic tasks (respiration, phonation and swallowing) and during the passage of the bolus. The possibility to test sensation is another extraordinary potentiality of the procedure. Subsequently, various standardized protocols for the dynamic study of swallowing have been proposed [17,18] but another advantage of endoscopy, in addition to those shown in Table 1, is exactly that of the possibility to adapt the evaluation to any kind of patient and in any kind of setting [19].


**Table 1.** Advantages and disadvantages comparison between VFSS and FEES [19]

patient in his/her totality, in relation to physical parameters (age, sex, race), the main pathology or other co-morbidities, the possibilities of an ecological management of the deglutition disorders (ie the possibility to effect behavioral strategies), also considering the wish of the

The systematic method of the FEES (fiberoptic endoscopic evaluation of swallowing) evalua‐

In this chapter the utility of endoscopy in the evaluation of dysphagic patients, new ways to conceive endoscopy and the correlations of endoscopy with a whole clinical context in the

In daily practice, an instrumental procedure is indicated in the face of any suspected dysphagia or when a definition in differential diagnostic terms of the oro-pharyngeal situation is required. An instrumental procedure is also indicated for patients with pathologies that carry a high risk of complications even if they are apparently asymptomatic or when there is a discrepancy between the subjective signs and the outcome of a bedside evaluation. Even the clinical onset of dysphagia with complications makes an instrumental investigation of swallowing necessary

The local availability of resources conditions the management of these patients but the possibility of a specialistic evaluation (carried out by a deglutologist) or the evaluation by trained carers has to be guaranteed in all the settings where elderly or dysphagic patients are recovered [1]. The tools, which are chosen, will be the available ones in our setting, aware that the "human factor" is the key to the success or failure of the clinical outcome. In our experience, the best way to manage dysphagic patients is represented by the evaluation of their swallowing abilities by means of a non instrumental clinical evaluation (clinical swallowing assessment,

Since 1988, when Susan Langmore first proposed the FEES protocol [16], the use of endoscopy in the evaluation of swallowing, has become an extraordinary tool in the hand of clinicians, offering a revolutionary way to observe the pharynx and the larynx during dynamic tasks (respiration, phonation and swallowing) and during the passage of the bolus. The possibility to test sensation is another extraordinary potentiality of the procedure. Subsequently, various standardized protocols for the dynamic study of swallowing have been proposed [17,18] but another advantage of endoscopy, in addition to those shown in Table 1, is exactly that of the possibility to adapt the evaluation to any kind of patient and in any kind of setting [19].

patient and of the family [1].

72 Seminars in Dysphagia

tion is reported elsewhere in this book.

**2. Instruments and settings**

[4-13].

So: which tool ?

attempt to determine severity, will be discussed.

CSA) [14] and an instrumental endoscopic evaluation [15].

**3. The endoscopic evaluation**

Firstly FEES has been compared and contrasted to VFSS (video-fluoroscopic study of swal‐ lowing) proposed by J. Logemann [20], an examination nowadays considered the instrumental gold standard for the study of swallowing. Compared to VFSS, FEES redeemed itself in terms of sensitivity, specificity and predictive values, if we consider its ability to identify aspiration as the main sensory-motor event linked to dysphagia and the leading cause of airway com‐ plications [21,19]. In a more recent period, the role of VFSS, as the instrumental gold standard, has been questioned [22].

Studies that have compared VFSS and FEES show that both procedures are comparable and have equivalent values of sensitivity, specificity and predictive abilities [23-30]. A more proper approach is to consider these two examinations as complementary [21]. The availability of both, allows the clinician to choose the method most appropriate to each case, relating to the required information. FEES also shows a considerable versatility in the management of the patients, of the multidisciplinary team and of the therapeutic process. The fact that it can be performed at the bedside, in any clinical condition and repeated over time, according to changing clinical needs, makes it an optimal method in the follow-up of any patient (Table 1).
