Dysphagia, difficulty swallowing safely and efficiently, poses significant health risks, including aspiration pneumonia, malnutrition and dehydration. For clinicians, accurately identifying swallowing impairments is critical to developing effective treatment plans and preventing avoidable complications. While bedside clinical evaluations play a key role in initial screening, they carry important limitations. The growing use of instrumental studies such as the fibre-optic endoscopic evaluation of swallowing (FEES) is helping to address many of these gaps.

What Is a Bedside Swallow Evaluation?
A bedside swallow evaluation is a non-instrumental procedure typically performed at the patient’s bedside. The clinician reviews the patient’s case history, assesses oral-motor and cranial nerve function, observes patient swallowing of saliva and often small volumes of liquids or soft food. They record signs such as coughing, throat clearing or wet-gurgly voice, and may trial different textures under supervision. The goal is to screen for risk of aspiration and to determine whether further testing is required. 

Key Limitations
Despite its value, the bedside evaluation has significant limitations that must be understood.

Inability to visualize the pharyngeal phase directly. Because the clinician can observe only external signs and the oral stage of swallowing, the pharyngeal phase which includes critical airway protection, timing of laryngeal closure and bolus clearance is not directly visible.

Low sensitivity for detecting silent aspiration and unobservable issues. A systematic review of bedside diagnostics found that no bedside protocol achieved sufficient predictive value to reliably detect aspiration, especially silent aspiration, when compared against instrumental reference standards.

Lack of reliability for certain patient populations (for example, stroke and neurogenic cases). Many bedside tools perform poorly in medically complex populations. Some studies report that bedside assessment may miss more than 50 % of aspiration cases in certain groups. 

Limitations in predicting the extent or type of dysphagia. A positive screen at bedside may indicate a swallowing disorder is present, but will not reliably specify the type (oral vs. pharyngeal), severity, or mechanism such as residue, penetration, or delayed swallow initiation. This limits how targeted treatment planning can be.

Instrumental Evaluations: FEES and VFSS
Instrumental assessments allow direct visualization of swallowing physiology. The Videofluoroscopic Swallow Study (VFSS) uses fluoroscopy and contrast to view bolus passage and anatomy in motion. The FEES procedure involves passing a flexible endoscope trans-nasally to visualize the pharynx and larynx during swallowing of real food and liquid. FEES has important advantages: it enables visualization of secretion management, residue, airway entry, effects of fatigue over a meal, and the use of therapeutic strategies in real time. By overcoming many of the blind spots inherent in bedside exams, FEES allows clinicians to tailor more precise treatment plans.

As FEES becomes more widely adopted, research is focusing on enhancing the structure and utility of reporting. For example, many centres now use validated scales within FEES (e.g., Penetration–Aspiration Scale, residue rating scales) to improve consistency and precision. Moreover, reporting frameworks are evolving to integrate severity ratings, swallowing phenotypes (types of impairment such as delayed swallow initiation vs impaired closure) and clinical context (e.g., patient fatigue, posture, real-meal performance) into a unified format. This trend responds to the variability and ambiguity that often accompany bedside descriptions, thus strengthening clinical decision-making.

Given the known limitations of bedside evaluations and the growing body of research supporting instrumental assessment, contemporary practice increasingly emphasises earlier referral for FEES when certain red flags are present (e.g., silent aspiration risk, neurological disorders, lack of clear findings at bedside). From a patient-centred perspective, using FEES can shorten the time to accurate diagnosis, provide better baseline data for therapy planning, and enhance patient education by showing physiologic findings in real time. For clinical teams, this means updating internal protocols, educating referral sources (e.g., physicians, therapists), and ensuring access to FEES services.

If you are evaluating patients with suspected dysphagia and want to enhance diagnostic accuracy, consider partnering with DiagnosTech FEES. We specialise in advanced FEES assessments, structured reporting and integrated therapy planning. Contact us to learn how our service can support your clinical pathway and improve patient outcomes.