We swallow hundreds of times a day, often without even thinking about it. In fact, swallowing is an action we perform several times every minute, seamlessly coordinating the tongue, throat, voice box and breathing muscles.
And every single time you swallow without food or liquid entering your airway, your body has pulled off a remarkably precise manoeuvre.
We take it for granted, until something goes wrong.
A cough while drinking. A change in the voice after swallowing. Repeated chest infections. Unexplained weight loss. Or sometimes, nothing obvious at all.
Because aspiration can happen silently.
So, how do we know what is really happening?
This is where swallowing endoscopy, or FEES (Flexible Endoscopic Evaluation of Swallowing), becomes incredibly valuable.
With a small flexible endoscope passed gently through the nose, we can watch the swallowing mechanism in real time while giving feeds of different consistencies. We can see how the throat moves, how well the airway is protected, where food or liquid is getting left behind and, most importantly, whether anything is finding its way into the airway.
We can also use specific swallowing manoeuvres during the examination to see whether they help prevent aspiration or improve the clearance of food and liquid from the throat.
It gives us something a routine bedside assessment cannot always provide: a window into what actually happens when you swallow.
The Examination Is More Than Just Watching
The word endoscopy can sound intimidating. But FEES is a relatively simple examination, usually performed with the patient awake and breathing normally.
A thin flexible camera is passed gently through the nose and positioned above the throat. We then give small amounts of food and liquid, often in different consistencies, while watching the swallow on a screen.
And this is where it becomes particularly interesting.
We don’t just watch the patient swallow. We can test.
- What happens with a sip of water?
- What happens with a thicker consistency?
- Does changing the head position help?
- Does a particular swallowing manoeuvre improve clearance?
- Does a smaller sip make the swallow safer?
The examination can become a real-time swallowing experiment.
We can try different strategies during the examination and immediately see whether they actually make the swallow safer or more efficient.
When Should We Think About FEES?
Not everyone who coughs while drinking needs a swallowing endoscopy. But FEES can be particularly useful when there is:
- Recurrent coughing or choking while eating or drinking
- A wet or gurgly voice after swallowing
- Recurrent chest infections or suspected aspiration
- Difficulty swallowing certain consistencies
- Neurological or neuromuscular conditions affecting swallowing
- Prolonged dependence on feeding tubes
- Uncertainty about whether oral feeding is safe
And importantly, sometimes the person doesn’t cough at all.
That is where silent aspiration becomes important. The absence of coughing does not necessarily mean that the airway is protected.
What Can We Do With the Information?
That information can change decisions.
- Can this patient safely eat and drink?
- Which consistency is safest?
- Is there a specific swallowing manoeuvre that can help them eat or drink better?
- Do they need swallowing therapy?
- Do they need an alternative feeding route, or can we confidently start oral feeding?
It is not simply about finding aspiration. It is about finding a way to make swallowing safer.
Our goal is not to take food away from someone. It is to help them eat and drink as safely and independently as possible.
A feeding tube may be necessary for some patients. But for others, a careful assessment may allow us to start oral feeding, modify the consistency, change the way they swallow, or use a simple manoeuvre that makes a significant difference.
Because eating and drinking are not just about nutrition. They are about independence, dignity, pleasure and quality of life.
Swallowing is something we do every day, without thinking. When it becomes difficult, it deserves to be understood, not guessed.
And sometimes, a tiny camera can make the difference between “I think it’s safe” and “I know it’s safe.”