Clinical decision-making (CDM) is one of the priorities of professional practice in the health field. CDM should be supported by scientific evidence and clinical experience, as well as the skills and judgment of the specialists and the patient’s clinical conditions, including values, expectations, and preferences. CDM depends on case management at the individual level and the formulation of clinical planning and cost-reduction strategies. However, in different areas of the health field, guidelines must be used to support the quality and accuracy of CDM.

In the oropharyngeal dysphagia (OD) field, the CDM transcends diagnostic investigation protocols and procedures, which are not always consensual, depending on the assessment procedure. Thus, among such diagnostic methods in the assessment of OD, fiberoptic endoscopic evaluation of swallowing (FEES) has become one of the frequently applied instrumental tools in research and clinical practice to assess OD and contribute to CDM¹.

The FEES, as well as other clinical and/or instrumental tests for OD diagnosis, still lack a standardized protocol regarding the procedures for carrying out the exam, the qualitative or quantitative temporal analysis parameters, and the interpretations of the outcomes. With the absence of a consensus for the FEES protocol, contributions become generic and can lead to interpretations for CMD that compromise the prognosis^2-4.

Thus, this report aims to contribute to CDM in OD based on the current scientific evidence from FEES and our experience of more than 24 years with dysphagia diagnosis and rehabilitation. Current evidence suggests that the exam still needs an international standardization of the consistencies and volumes of food, utensils, task sequences, and the implementation of rehabilitation techniques for safe and efficient swallowing as a mandatory protocol in performing the exam. In addition, many evaluations, analyses, and classification parameters can compromise the standardization of findings and the CDM. Therefore, at this point, it is sine qua non that all clinicians establish guidelines first to standardize their FEES protocol and, subsequently, create solid bases for CDM. The absence of guidelines, leading to a non-linear execution, compromises outcome findings and analysis. While generic descriptive reports may acknowledge the presence of laryngeal sensitivity, posterior oral spillage, pharyngeal residues, penetration, and laryngotracheal aspiration, they fall short of elucidating the underlying mechanisms behind these findings. Thus, for example, pharyngeal residues or aspiration should never imply generic CDM.

Given the FEES findings, we will move on to re-thinking, which can contribute to the interpretation of CDM in dysphagic cases. The investigation of laryngeal sensitivity impairment has a guiding hypothesis based on the impact of this parameter on laryngotracheal aspiration risk and, therefore, how much the CDM would be affected by such impact. The evidence is still contradictory even to prove the hypothesis, with findings that confirm it in specific dysphagic stroke populations⁵. One of the quantitative parameters measured is posterior oral spillage (POS) time, which can be associated with delayed pharyngeal response. POS time is very similar among individuals, with differences measured in milliseconds. Therefore, when comparing POS times, it is necessary to include many subjects.

Nevertheless, a millisecond decrease in swallowing is significant to the security of the swallowing function. Meanwhile, there are so many other active risk mechanisms in this population that an isolated finding should not be considered independently in the final decision. Since FEES is a procedure with different analysis parameters, there is an obstacle regarding the exam outcomes or how to determine its primary outcome. Therefore, the hierarchy of FEES outcomes should be done according to their relative degree of relevance for CDM. However, this needs to be observed in clinical practice.

One possible reason for these difficulties is the lack of standardization in the selection and interpretation of parameters such as posterior oral spillage, pharyngeal residues, penetration, and aspiration by FEES. Although rating scales exist for some of these parameters, they differ and do not support CDM in isolation. In this process, in addition to understanding how these findings interact with each other, the professional must consider how they behave according to the adjacent pathophysiology and within the patient’s dietary context.

In the clinical practice of the professional who works with OD, there is substantial concern about the risks of laryngotracheal aspiration, as if this were the only objective of FEES when often the type, volume, and frequency of this aspiration could not even be evaluated in a single FEES exam. This issue often leads, wrongly and prematurely, on the part of the clinician, to the prohibition or withdrawal of partial oral feeding, as well as the exclusion of more effective therapy with partial oral feeding training. It is a fact that the presence of aspiration in OD is an element of concern, on the other hand, the efficiency of swallowing and the impact on nutritional intake should have the same importance in CDM. However, in FEES, what findings should be considered in CDM to enhance our view on the efficiency of swallowing and its impact on nutritional intake? Considering that FEES does not visualize the oral phase of swallowing, and this is a relevant biomarker for CDM in OD, we suggest that the posterior oral spillage, indeed associated with pharyngeal performance, and the other findings of the clinical diagnostic are included like relevant elements for the decision about the possibility of oral feeding, even though there is safety for swallowing.

FEES is an OD diagnostic investigation exam that certainly has advantages. However, using this resource in CDM in OD will require much more rethinking about all the other elements of the clinical evaluation of OD. CDM in OD requires multifactorial knowledge, and although FEES brings contributions, this is undoubtedly one of the swallowing assessment methods that will most require interpretation by the clinician. In oropharyngeal dysphagia, the pharyngeal findings found during the FEES cannot only be described but must also be interpreted in a clinical context by a specialist in swallowing for assertive decision-making.

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