Disparate Practice Patterns in Dysphagia Diagnostics With Flexible Endoscopic Evaluation of Swallowing: An Exploratory Study

Purpose: The purpose of this study was, first, to explore current intraprofessional flexible endoscopic evaluation of swallowing (FEES) interpretation practices, expecting lack of methodological consensus. Second, it aimed to compare penetration–aspiration scale (PAS) ratings on FEES exams using Langmore-defined versus Visual Analysis of Swallowing Efficiency and Safety (VASES)–defined anatomical boundaries, hypothesizing that using the Langmore framework would yield more “abnormal” scores than the VASES, due to more conservatively defined anatomical boundaries. Method: FEES training course vendors and FEES clinical practitioners across the United States were surveyed regarding the anatomical boundaries they employ. Expert raters at a tertiary care center reviewed recorded FEES exams and rated PAS scores using either Langmore or VASES boundaries. Statistical analyses compared (a) the frequency of normal versus abnormal scores and (b) the frequency of PAS 1 and PAS 3 between the frameworks, representing the threshold for dysphagia diagnosis. Results: There is notable intraprofessional inconsistency regarding FEES exam interpretation. There was a significant difference in the rates of normal versus abnormal PAS scores, with Langmore boundaries yielding more abnormal scores than VASES. Most notably, a significant difference was found in the frequency of PAS 1 (no airway invasion) versus PAS 3 (sustained penetration) between frameworks. Conclusions: Two framework options guide PAS ratings, which differ in their defined anatomical boundaries, directly impacting dysphagia diagnosis. Experienced clinicians adhering to the highest standards of evidence-based practice may still regularly misdiagnose dysphagia with wide-ranging implications for patients. The findings highlight a need to establish a consistent approach to dysphagia diagnostics with FEES and offer a concrete area of opportunity for improved standardization and accuracy. Supplemental Material: https://doi.org/10.23641/asha.34790430