THE ROLE OF FESS (FLEXIBLE ENDOSCOPY 

EVALUATION OF SWALLOWING) 
IN MANAGING DYSPHAGIA PATIENTS

SUSYANA TAMIN
ELVIE ZULKA KAUTZIA
Endoscopy Bronchoesophagology division
ENT Department , Medical Faculty, University of
Indonesia, Dr. Cipto Mangunkusumo Hospital,
Jakarta
 DYSPHAGIA

• Any subjective or objective patient

complaint of difficulty swallowing or
handling food or secretions
• coughing, choking before, during and
after meal.
• abnormal swallowing due to impaired
coordination, obstruction, or weakness
affecting swallowing biomechanics
 DYSPHAGIA
TRANSPORTATION NUTRITION
FOOD / SALIVA ASPIRATION PROBLEMS

AIRWAYS DEHYDRATION
ASPIRATION
PROTECTION PNEUMONI
160.000
CASES/YEAR MALNUTRITION

SWALLOWING AIRWAYS
OBSTRUCTION
IMUNITY
PROBLEM
DEATH
50.000
CASES/YEAR Neurologi 1988,38
Stroke 1988,19
.
 INTRODUCTION
Introduction

Stroke
Early diagnosed
(FEES) Other motoric problem
Disfagia
(22 -50%)*

Reduce nutrition
Aspiration (23%)* Delayed of
intake
swallowing
function recovery

Silent
aspiration
Pneumonia
Immediate
(19%)*
treatment
†
* Terre R, Mearin F. Oropharyngeal dysphagia after the acute phase of stroke: predictors of aspiration.
Neurogastroenterol motil 2006; 18: 200-5
AIRWAYS PROTECTION

PENETRATION ASPIRATION/
SILENT ASPIRATION
PENETRATION/ASPIRATION
PENETRATION/ASPIRATION

™ Before swallowing reflex :

¾ Inadequate tongue control
¾ Delayed swallowing reflex
™ During swallowing process
¾ Abnormality in laryngeal elevation and
laryngeal closure
™ After swallowing reflex
¾ Unilateral/bilateral pharyngeal wall
paralyzed, cricopharyngeal dysfunction
( residu )
(Logemann, 1998)
 ASPIRATION PNEUMONI

• Recurrent Aspiration Pneumonia Æ deadly

• 50.000 deaths in a year caused by
aspiration pneumonia post stroke
(20-65%)

Neurologi 1988,38

Stroke 1988,19
 FEES

„ Objective evaluation of swallowing

process Æ FEES :
– Best with visualitation

– Silent aspiration

– Dysphagia in patients : oral

and pharynx phase
 THE CLINICAL CONCERN OF FEES

Diagnosis
Therapy :          
How to   
swallow safely
 PROBLEMS
™ The requirement for
nasogatric tube ?
™ The time to remove the
nasogastric tube ?
™ The potential danger for
oral feeding ?
™ The kind of suitable food
for dysphagia patients?
 INDICATIONS OF FEES

Concerns about :
alterations in nasopharyngeal, 
oropharyngeal, or laryngeal anatomy 
sensoric integrity of pharyngeal and/or  
laryngeal structures.
the patient’s ability to initiate and 
maintain airway protection
high risk for aspiration, 
assessment of pharyngeal constriction
 ADVANTAGE & DISADVANTAGE

ADVANTAGE
to detect abnormality of
swallowing mechanism and
DISADVANTAGE
evidence of aspiration
• Blind spot
to perform evaluation for using • can evaluate neither
NGT cricopharyngeus nor
to provide on-line visual esophagus directly
feedback
to assess the effects of various
strategies, i.e., head turning,
breath holding repeatedly
 TARGETS

PATIENTS WITH DIFFICULTY IN SWALLOWING

– Head & neck tumor patients with dysphagia
– Head and neck Cancer patients after operation,
radiotherapy and chemotherapy
– Stroke / post stroke patients
– Other neuromuscular problems
– Geriatric patients with dysphagia
– Laryngofaringeal reflux with dysphagia