**8. Conclusions**

In conclusion, some observations can be made.

The first consideration is that a criterion of severity must be a complete clinical criterion, which considers as many elements as possible from the clinical non-instrumental and instrumental evaluation. In general, any event leading the team to modify the treatment programme already decided, can become element of severity. As previously said, the only CSE, however well conducted, may underestimate the severity of a swallowing disorder in relation to the inability to directly see the effectors of swallowing and their behavior during the passage of the bolus. The contribution of the instrumental examination, in this issue, is essential: It shows the clinicians what happens inside the effectors during the passage of the bolus, but it tends to overestimate the severity of the disorder, inducing in the risk of generalization of patterns that may not reflect the real functional status of the effectors.

The endoscopic examination is a versatile and well-tolerated tool, which promptly facilitates and ratifies the team's activities. The latest developments of the endoscopic investigation with the possibility of a direct visualization of the oral (O-FEES) and the esophageal (E-FEES) phase of swallowing makes FEES more complete and brings it closer to the radiological gold standard.

Compared to VFSS, endoscopy allows for an optimal viewing of the effectors, making us appreciate all the anatomical variations that can affect the passage of the bolus. The interpre‐ tation of the biomechanical events resulting from this passage should enable the clinician to estimate behaviors useful for therapeutic purposes.

Taken together, all this information will provide us with a complete criterion of severity, able to guide the team towards effective activities and improve the QOL of the patient.
