Table 3.

Analysis of selected studies.

Author, publication date	Neurogenic disease	Number of patients/sex	Associated Evaluation	FEES steps	Tested consistencies (food/utensil)	Volumes	FEES results in swallowing function
Warnecke et al., 2009 29	Acute stroke	153 (80 women)	Dzeiwas protocol performed by neurologist and speech therapist	1. Structural evaluation initially with endoscopy	a. Pasty	a. Teaspoon of puree	6-point scale to determine the severity of dysphagia, where 1 = no laryngeal penetration or laryngotracheal aspiration with soft solid (no change) and 6 = penetration or aspiration with saliva (severe)
					b. Liquid
					c. Soft-solid	b. Teaspoon of water with food contrast
			FEES 24 h after hospital admission	2. Evaluation of secretion management
				3. Functional evaluation of swallowing		c. Small piece of white bread
						Note: Quantity and number of offers not specified
Warnecke et al., 2010 26	PSP	18/11 men	Levodopa-test; FEES with monitoring by ENT doctor and speech therapist	1. FEES in the “off” state of levodopa;	a. Pudding (gelatin)	a. 3 × 8 mL pudding	Posteriorleakage of food or liquid;
	PD	15/11 men			b. Liquid (water)	b. 3 × 5 mL liquid
				2. 200 mg dose of levodopa administered	c. Soft solid (white bread)	c. 3× pieces of bread (3 cm/3 cm/0.5 cm)	Penetration and/or aspiration events;
				3. New FEES was performed after 60 min	Note: All foods colored blue or green		Presence or absence of waste
Mandysova et al., 2011 21	Stroke	87/ND	Brief Bedside Dysphagia Screening Test	1. Physical assessment – motor function of muscles and reflexes involved in swallowing;	a. Thick liquid	a. Four teaspoons	Penetration-aspiration scale by Rosenbek et al.
	MG
	PD
	ALS		FEES with ENT doctor and nurse monitoring		b. Thin liquid (spoon)	b. Four teaspoons
	ENT
				2. Functional assessment of swallowing	c. Thin liquid (glass)	c. 60 mL in the glass
					d. Assessment of patient voice after swallowing	Note: If the patient coughs, chokes, has a wet voice or leaks from the mouth in <1 min, the test was interrupted.
					Note: Not specified if the food was colored during the exams
D’Ottaviano et al., 201331	ALS	11 (6 men)	Protocol described in the study, monitored by ENT doctor and speech therapist	1. Swallowing self-assessment questionnaire	a. Pasty (water plus two tablespoons of the thickener Resource Thicken Up - Nestlé®	a. 5 and 10 mL	Posteriorleakage
						b. 5 and 10 mL	Food residue
				2. Assessment of tongue mobility and fasciculations		c. Half of salt and water cracker	Laryngeal penetration
							Tracheal aspiration
				3. Functional assessment of swallowing	b. Liquid (water)		Timing until tracheal aspiration occurs
					c. Solid (cracker)
					Note: All foods colored blue.		Response to tracheal aspiration
Pilz et al., 201436	DM1 Controls	45 DM1 (28 men)	Langmore Protocol2 Functional Oral Intake Scale (FOIS) Monitored by ENT doctor and speech therapist.	1. Seated patient	a. Thin liquid (water)	a. 10 mL (3 offers)	FOIS scale and visual perception of variables during FEES:
		10 controls (7 women)		2. Evaluation of functionality and morphology of oropharyngeal structures	b. Thick liquid (applesauce)	b. 10 mL (3 offers)
					c. Solid (cracker)	c. 1 piece of solid	Multiple swallows
					Note: All foods colored blue.		Latency at the beginning of the pharyngeal reflex
				3. Food bolus or liquid inserted into the oral cavity using a syringe			Valecule residue after swallowing
							Residue on piriform sinuses after swallowing
							Laryngeal penetration or tracheal aspiration
Somasundaram et al., 201437	Middle cerebral artery acute stroke	67 (all men)	Initial visit – complete medical history;	FEES performed by an experienced speech therapist and neurologist; Langmore Protocol 2;	1. Thickened liquid	a. 3× thickened water	Assessment of dysarthria, dysphonia, volitional cough, and gag reflex;
					2. Semi-solid	b. 3× pudding
			Physical examination; EAT-10 before FEES;		3. Liquid	c. 3× water
				1. Structural evaluation	4. Solid	d. 3× white bread	Penetration-aspiration scale
			Cynical Assessment of Swallowing – local protocol; FEES;	2. Observation of secretion or saliva accumulation	Note: All consistencies were stained with blue food coloring.	Note: Quantities not specified.	In the presence of pharyngeal residue, the patient was observed for 2 min to identify voluntary swallowing afterwards, for oral cleaning;
			Note: stroke unit patients screened by doctors and evaluated by a speech therapist 24 h after admission.	3. Functional assessment of swallowing
Leder et al., 201622	Hospitalized elderly	961 (524 men)	Yale Swallow Protocol FEES – with modified Langmore Standard Protocol, as a complementary assessment for some patients; Monitored by ENT doctor and speech therapist	1. Visualization of the most patent nostril for passing an endoscope without anesthesia;	a. Pasty (pudding)	5 to 10 mL for each consistency	Presence or absence of tracheal aspiration;
					b. Liquid (skim milk)
					c. Solid (cracker)
				2. Morphological evaluation of oropharyngeal structures;	Note: Not specified if food was colored during the exams		Functional swallowing defined with absence of aspiration;
				3. Functional assessment of swallowing			Non-functional swallowing with the presence of aspiration in any of the consistencies tested during FEES.
Marian et al., 201732	Stroke	50 (25 each sex)	Screening for swallowing with water, in the presence of predictive symptoms of dysphagia, referral to FEES; Langmore Protocol with modifications; 6-point scale for stroke; Clinical monitoring by neurologist and speech therapist.	1. Patients evaluated in bed with elevated headboard in a stroke unit	a. Pasty (pudding)	3 × 3 mL for each consistency	Penetration-aspiration Scale – FEEDS scale – 6-point dysphagia severity scale in endoscopic evaluation (1 = the best performance and 6 = the worst performance)
					b. Liquid (not specified)
					c. Soft solid (white bread)
				2. Endoscope was passed through the most patent nostril with application of local anesthetic	Note: All foods colored blue
				3. Secretion accumulation in the oropharyngeal region evaluated according to the severity scale
				4. Functional assessment of swallowing
de Lima Alvarenga et al., 201823	Elderly >60 years	100 elderly (58 women)	Initial interview Modified Langmore Protocol Medical monitoring.	Self-administered by the participant:	a. Strawberry pudding	a. 10 mL	Evaluated as outcomes:
				1. Assessment of swallowing function	b. Skim milk	b. 50 mL in a glass	1. Saliva stasis in the pharynx
					c. Cracker	c. 1 cracker	2. Pharyngeal residue
					Note: Foods colored green with food coloring.		3. Laryngeal penetration
							4. Laryngotracheal aspiration
							5. Laryngeal sensitivity.
Nienstedt et al., 201827	PD	119 PD	FEES with ENT doctor monitoring;	1. Lidocaine application	a. Liquid	a. 90 mL water	Penetration-aspiration scale, Murray scale short version
		32 Control			b. Solid
			Assessments: MDS-UPDRS; H&Y scale; NMS-Quest; MOCA DSFS	2. Functional assessment of swallowing	c. Soft solid	b. Cracker (91 mm and 20 g)
						c. Half a bread with butter (94 × 90 × 9 mm, 28 g)
Pflug et al., 201828	PD	119 PD	FEES with ENT doctors blinded to disease stages; MDS-UPDRS Evaluation H&Y scale NMS-Quest MOCA Assessment of depression – Beck questionnaire, German version	1. Initial evaluation by ENT doctor with a request to: cough or throat clearing after eating or drinking; history of aspiration or pneumonia;	a. Liquid	a. Teaspoon for water	Scale of swallowing restrictions – SSR
		32 Control			b. Solid
					c. Soft solid
						b. 90 mL water with straw	Penetration-aspiration scale
						c. 1 cracker (91 mm, 20 g)
				2. Functional assessment of swallowing		d. Half a piece of bread with butter (95 × 90 × 9, 28 g)	Premature leakage and waste.
Umay et al., 201840	MG	36 MG (20 women)	FEES	1. Without anesthesia	a. Liquid	a. Water (90 mL)	A score of 1−6 was used for the degree of dysphagia (1 = normal swallowing and 2–6 = dysphagia – from mild to severe.
			Manometry	2. Dzeiwas protocol	b. Semi-solid	b. Yogurt
		25 Control (14 women)	EAT-10		c. Solid	c. Cracker
			Surface electromyography
			VFD
Braun et al., 201924	Post-stroke elderly	152 (94 men)	GUSS	1. Nasal decongestant application (Xylometazoline) and local anesthesia (2% lidocaine gel)	a. Pasty	a. 3× water with thickener	Rosenbek penetration-aspiration scale.
			FEES considering Langmore standard protocol for signs and symptoms of dysphagia		b. Liquid	b. 3× thin water
					c. Solid	c. 3× solid (unspecified)
							Outcomes: FOIS, FEDSS
				2. Observation of anatomical structures, mobility of structures and saliva management		Note: Offer in teaspoon; soup spoon; and sip from glass.
				3. Functional assessment of swallowing
Farneti et al., 201941	Different etiologies: PD, vascular dementia, stroke, TBI.	16 adults (11 men)	Own protocol with consistencies based on the global initiative FEES associated with penetration-aspiration scale, FOIS, and DOSS	1. Functional assessment of swallowing	a. Pasty	a. 5cc puree	Videos evaluated by 2 independent and experienced FEES evaluators.
					b. Solid	b. 1∕4 cracker (salt and water)
					c. Liquid
						c. 5cc liquid
							Swallowing performance assessed using: Penetration-aspiration scale, FOIS, and DOSS.
							Outcome: average time for cleaning residues / consistency.
Imaizumi et al., 201934	Elderly people with different comorbidities: cerebrovascular disease, dementia, PD	106 (76 women):	FEES performed on patients at risk for dysphagia based on responses to two questionnaires such as EAT-10 Screening with FEES	1. FEES performed by ENT doctor	a. Degree of saliva accumulation in the vallecula and piriform sinuses;	Saliva	FEES associated with the Penetration-Aspiration Scale
		G1 – detectable swallowing alteration;		2. Food-free assessment based on a system developed by Hyodo et al.	b. Glottic closure reflex with touch of endoscope in epiglottis or arytenoid		Level of care required
			Without food – to identify the severity of swallowing changes				Consciousness level
		G2 – swallowing change not detectable					Ability to eat orally
					c. Reflex of onset of swallowing based on white-out time		Skills in activities of daily living
					d. Pharyngeal cleaning and clearance after swallowing 3 mL of colored water
Suntrup-Krueger et al., 201925	Acute stroke, recently extubated	133	FEES performed 48 h after extubation monitored by a speech therapist and neurologist.	1- Evaluation of secretion management	a. Pasty	Volumes not specified for each consistency	Sensitivity (intact, reduced, or absent)
					b. Liquid
					c. Soft solid
				2- Observation of spontaneous swallowing per minute
							FEDSS >1 considered as dysphagia
			Extubation Assessments:	3- Assessment of laryngeal sensitivity by touching pharyngolaryngeal structures			3-ounce water swallow test performed 72 h after extubation and 24 h after FEES
			Glasgow coma scale; Body temperature; Heart beats; Systolic pressure; Spontaneous breathing in volume; Positive exhalation pressure; Rapid shallow breathing index
				4- FEES protocol validated for post-stroke patients
Schröder et al., 201935	PD	Cohort of 105 patients, 20 selected patients:	Langmore Protocol	1. Functional assessment of swallowing	a. Pasty	a. Green jelly	Premature leakage
					b. Liquid		Penetration-aspiration events
					c. Soft solid	b. Blue colored water
						c. White bread (3 × 3×0.5 cm)	Residues assessed using dysphagia severity scale of 0–3, where 0 = no swallowing changes and 3 = severe dysphagia (penetration-aspiration with 2–3 consistencies).
		G1 – 10 without signs of dysphagia;
		G2 – 10 with signs of pharyngeal dysphagia
							Substance P from saliva was collected in G1 and G2
Shapira-Galitz et al., 201930	Stroke	136 (25 from Kaplan Medical Center and 111 from Sheba Medical Center)	Langmore Protocol with minor modifications	1. Small amount of local anesthesia (2% Lidocaine hydrochloride gel)	a. Pasty	a. Applesauce with green dye (with spoon)	Penetration-aspiration scale
	TBI				b. Solid
	Degenerative neuromuscular diseases				c. Liquid
						b. Whole meal bread (two pieces with crust and one without crust)	Residues determined as 0 if absent in all consistencies and as 1 for residue presented in each consistency, with a maximum score of 3 if present in the three consistencies
		51 control		2. Functional assessment of swallowing		c. 3% fat milk with green dye (with straw and straight from the glass)
						Note: 3 offers of each consistency, with approximately 5cc of volume each bolus
Souza et al., 201938	DM 1	1 (male, 66 years)	Clinical swallowing evaluation	1. FEES by ENT doctor and speech therapist	a. Pasty	a. Peach flavored dietary juice	Laryngeal sensitivity
			FEES performed by doctor.		b. Thickened liquid		Premature oral leakage
				2. Assessment of laryngeal sensitivity	Note: Consistencies according to IDDSI	b. Juice with instant thickener
							Pharyngeal waste
				3. Functional assessment of swallowing		Note: All consistencies were stained with blue food coloring.	Laryngotracheal penetration and aspiration
						Consistencies offered in 3, 5 and 10 mL using disposable spoons
Souza et al., 201939	Stroke	G1: 10 (stroke – 8 men);	FEES performed by physician	1. FEES performed without anesthesia	a. Pasty	Note: All consistencies stained with blue food coloring (5 mL offered), without description of the number of offers and which foods for each consistency.	Pharyngeal waste scale based on the YPRSSRS scale
	ALS				b. Thickened liquid
	PD	G2: 10 (ALS – 5 men);		2. Functional assessment of swallowing with institutional protocol
		G3: 10 (PD – 5 men)			Note: Consistencies according to IDDSI
Institutional protocol for functional swallowing assessment	2. Laryngeal sensitivity was assessed by touch with nasofibroscope on the aryepiglottic and arytenoid folds	20 (13 men)	FEES performed by ENT doctor and speech therapist concomitantly	1. Structures observed in motion, initially with emission of the vowel ∕ i ∕	a. Pasty	Note: Without details of the quantity offered in each consistency	Posteriororal leakage;
					b. Thickened liquid
					c. Liquid		Pharyngeal residue;
					Note: Consistencies according to IDDSI		Laryngeal penetration;
				3. Functional assessment of swallowing
							Laryngotracheal aspiration

FEES, fiberoptic endoscopic evaluation of swallowing; ENT doctor, otorhinolaryngologist; PSP, progressive supranuclear palsy; PD, Parkinson's disease; MG, myasthenia gravis; ALS, amyotrophic lateral sclerosis; ND, no data; DM 1, Muscular Dystrophy type 1; FOIS, Functional Oral Intake Scale; FEEDS, Functional Evaluation of Eating Difficulties Scale; MDS-UPDRS, Movement Disorder Society’s Unified Parkinson’s Disease Rating Scale; H&Y, Hoehn & Yahr scale; NMS-Quest, Non-Motor Symptoms Assessed by Non-Motor Symptoms Questionnaire; MOCA, Montreal Cognitive Assessment; DSFS, Drooling Severity and Frequency Scale; mL, milliliter; mm, millimeter; mg, milligrams; cc, cubic centimeter; SSR, Sympathetic Skin Responses; VFD, Videofluoroscopy of Deglutition; GUSS, Gugging Swallowing Screening; DOSS, Dysphagia Outcome and Severity Scale; IDDSI, International Dysphagia Diet Standardization Initiative; YPRSSRS, Yale Pharyngeal Residue Severity Rating Scale.