VFSS vs FEES: Choosing the Right Instrumental Swallowing Assessment

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When it comes to assessing swallowing function, clinicians often ask, “Should I refer for a VFSS or a FEES?”At Swallow Science Melbourne, we offer both assessments because each provides unique insights. Understanding when and why to use each tool helps ensure patients receive the most targeted and efficient care.

A quick overview

Videofluoroscopic Swallow Study (VFSS) allows us to see the oral, pharyngeal and upper oesophageal phases in real time as the patient swallows contrast material (barium) in a radiology suite.

Flexible Endoscopic Evaluation of Swallowing (FEES) gives us a clear view of the hypopharynx and airway. FEES is radiation-free and can be performed in a clinic setting.

Both studies are complementary rather than competing. VFSS visualises the movements of swallowing; FEES shows what happens to the airway during swallowing.

When VFSS may be preferred

VFSS is ideal when we need to visualise bolus flow through all phases of swallowing or investigate structural or oesophageal issues. It provides information about oral containment, tongue propulsion, and upper oesophageal sphincter opening.

Typical referral reasons include:

• Suspected cricopharyngeal dysfunction

• Poor oral bolus control or delayed oral transit

• Need for imaging of timing and coordination

• Concern about oesophageal clearance

VFSS requires a medical referrer to complete an imaging slip and cannot be referred by a speech pathologist (though a clinician may initiate these discussions and recommend the assessment).

When FEES may be preferred

FEES is particularly powerful for understanding pharyngeal and laryngeal physiology, secretion management, and airway protection. It gives a close-up view of laryngeal movement, secretions, and sensory responses - features not captured on VFSS.

FEES is well suited to clients who:

• Have airway compromise, secretion pooling or aspiration concerns

• Experience fatigue or need multiple trials during a single assessment session

• Have conditions where repeat assessments are needed (e.g. when viewing improvement over time with therapy, or progressive changes)

• Cannot easily travel to a radiology suite

FEES can be referred by speech pathologists, can be performed safely in the clinic, with immediate feedback and without radiation exposure.

Comparing at a glance

Feature	VFSS	FEES
Visualises oral phase	✅ Yes	❌ No
Visualises oesophageal phase	✅ Yes	❌ No
Visualises submucosal anatomy (e.g. skeletal structures)	✅ Yes	❌ No
Suspected cricopharyngeal / UES dysfunction	✅ Yes	❌ No
For diagnostics / unknown aetiology	✅ Yes	❌ Limited
Base of tongue movement / bolus propulsion	✅ Yes	⚪ Indirect
Visualises pharyngeal and laryngeal structures	⚪ Indirect	✅ Yes
Airway protection and laryngeal closure	⚪ Indirect	✅ Yes
Conservative exam (e.g. ice chips, secretion-only)	⚪ Limited	✅ Yes
Use of real foods and drinks	⚪ Limited	✅ Yes
Repeat assessment to review progress	⚪ Limited	✅ Yes
Evaluates secretion issues	❌ Limited	✅ Yes
Visualises mucosa, colour, oedema, vocal fold movement	❌ No	✅ Yes
Response to laryngopharyngeal sensation	❌ No	✅ Yes
Full-meal / fatigability testing	❌ No	✅ Yes
Avoids radiation	❌ No	✅ Yes
Portability / bedside access	❌ No	✅ Yes

Table adapted from Langmore (2006)

Why we offer both

At Swallow Science Melbourne, we see VFSS and FEES as two sides of the same coin. FEES allows us to examine secretions, fatigue, and airway protection in the clinic. VFSS helps us understand propulsion, oral containment, and oesophageal clearance under imaging.

Used together, they provide a complete picture of swallowing function - particularly valuable for clients with complex, progressive, or fluctuating presentations.