, Volume 32, Issue 3, pp 443–448 | Cite as

Narrow Band Imaging Enhances the Detection Rate of Penetration and Aspiration in FEES

  • Julie C. Nienstedt
  • Frank Müller
  • Almut Nießen
  • Susanne Fleischer
  • Jana-Christiane Koseki
  • Till Flügel
  • Christina PflugEmail author
Original Article


Narrow band imaging (NBI) is widely used in gastrointestinal, laryngeal, and urological endoscopy. Its original purpose was to visualize vessels and epithelial irregularities. Based on our observation that adding NBI to common white light (WL) improves the contrast of the test bolus in fiberoptic endoscopic evaluation of swallowing (FEES), we now investigated the potential value of NBI in swallowing disorders. 148 FEES images were analyzed from 74 consecutive patients with swallowing disorders, including 74 with and 74 without NBI. All images were evaluated by four dysphagia specialists. Findings were classified according to Rosenbek’s penetration-aspiration scale modified for evaluating these FEES images. Intra- and inter-rater reliability was determined as well as observer confidence. A better visualization of the bolus is the main advantage of NBI in FEES. This generally leads to sharper optical contrasts and better detection of small bolus quantities. Accordingly, NBI enhances the detection rate of penetration and aspiration. On average, identification of laryngeal penetration increased from 40 to 73% and of aspiration from 13 to 24% (each p < 0.01) of patients. In contrast to WL alone, the use of NBI also markedly increased the inter- and intra-rater reliability (p < 0.01) and the rating confidence of all experts (p < 0.05). NBI is an easy and cost-effective tool simplifying dysphagia evaluation and shortening FEES evaluation time. It leads to a markedly higher detection rate of pathological findings. The significantly better intra- and inter-rater reliability argues further for a better overall reproducibly of FEES interpretation.


Deglutition Deglutition disorders Narrow band imaging (NBI) FEES Laryngeal penetration Aspiration 


Compliance with Ethical Standards

Conflict of interest

The authors have no conflict of interest to declare.

Ethical Statement

The study was conducted in compliance with the Helsinki Declaration.


  1. 1.
    Langmore SE, Schatz K, Olsen N. Fiberoptic endoscopic examination of swallowing safety: a new procedure. Dysphagia. 1988;2(4):216–9.CrossRefPubMedGoogle Scholar
  2. 2.
    Langmore SE, Schatz K, Olson N. Endoscopic and videofluoroscopic evaluations of swallowing and aspiration. Ann Otol Rhinol Laryngol. 1991;100(8):678–81.CrossRefPubMedGoogle Scholar
  3. 3.
    Colodny N. Interjudge and intrajudge reliabilities in fiberoptic endoscopic evaluation of swallowing (fees) using the penetration-aspiration scale: a replication study. Dysphagia. 2002;17(4):308–15. doi: 10.1007/s00455-002-0073-4.CrossRefPubMedGoogle Scholar
  4. 4.
    Deutschmann MW, McDonough A, Dort JC, Dort E, Nakoneshny S, Matthews TW. Fiber-optic endoscopic evaluation of swallowing (FEES): predictor of swallowing-related complications in the head and neck cancer population. Head Neck. 2013;35(7):974–9. doi: 10.1002/hed.23066.CrossRefPubMedGoogle Scholar
  5. 5.
    Leder SB, Sasaki CT, Burrell MI. Fiberoptic endoscopic evaluation of dysphagia to identify silent aspiration. Dysphagia. 1998;13(1):19–21. doi: 10.1007/PL00009544.CrossRefPubMedGoogle Scholar
  6. 6.
    Kelly AM, Drinnan MJ, Leslie P. Assessing penetration and aspiration: how do videofluoroscopy and fiberoptic endoscopic evaluation of swallowing compare? Laryngoscope. 2007;117(10):1723–7. doi: 10.1097/MLG.0b013e318123ee6a.CrossRefPubMedGoogle Scholar
  7. 7.
    Rosenbek JC, Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetration-aspiration scale. Dysphagia. 1996;11(2):93–8.CrossRefPubMedGoogle Scholar
  8. 8.
    Rosen CA, Amin MR, Sulica L, Simpson CB, Merati AL, Courey MS, Johns MM 3rd, Postma GN. Advances in office-based diagnosis and treatment in laryngology. Laryngoscope. 2009;119(Suppl 2):S185–212. doi: 10.1002/lary.20712.CrossRefPubMedGoogle Scholar
  9. 9.
    Yoshida T, Inoue H, Usui S, Satodate H, Fukami N, Kudo SE. Narrow-band imaging system with magnifying endoscopy for superficial esophageal lesions. Gastrointest Endosc. 2004;59(2):288–95. doi: 10.1016/S0016-5107(03)02532-X.CrossRefPubMedGoogle Scholar
  10. 10.
    Watanabe A, Tsujie H, Taniguchi M, Hosokawa M, Fujita M, Sasaki S. Laryngoscopic detection of pharyngeal carcinoma in situ with narrowband imaging. Laryngoscope. 2006;116(4):650–4. doi: 10.1097/01.mlg.0000204304.38797.34.CrossRefPubMedGoogle Scholar
  11. 11.
    Piazza C, Dessouky O, Peretti G, Cocco D, De Benedetto L, Nicolai P. Narrow-band imaging: a new tool for evaluation of head and neck squamous cell carcinomas. Review of the literature. Acta Otorhinolaryngol Ital. 2008;28(2):49–54.PubMedPubMedCentralGoogle Scholar
  12. 12.
    Arens C, Betz C, Kraft M, Voigt-Zimmermann S. Narrow band imaging for early diagnosis of epithelial dysplasias and microinvasive tumors in the upper aerodigestive tract. HNO. 2016;64(1):19–26. doi: 10.1007/s00106-015-0108-4.CrossRefPubMedGoogle Scholar
  13. 13.
    Muto M, Nakane M, Katada C, Sano Y, Ohtsu A, Esumi H, Ebihara S, Yoshida S. Squamous cell carcinoma in situ at oropharyngeal and hypopharyngeal mucosal sites. Cancer. 2004;101(6):1375–81. doi: 10.1002/cncr.20482.CrossRefPubMedGoogle Scholar
  14. 14.
    Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159–74.CrossRefPubMedGoogle Scholar
  15. 15.
    Hey C, Pluschinski P, Pajunk R, Almahameed A, Girth L, Sader R, Stover T, Zaretsky Y. Penetration-aspiration: is their detection in FEES (R) reliable without video recording? Dysphagia. 2015;30(4):418–22. doi: 10.1007/s00455-015-9616-3.CrossRefPubMedGoogle Scholar
  16. 16.
    Langmore SE. Endoscopic evaluation and treatment of swallowing disorders. 2nd ed. New York: Thieme Verlag; 2000.Google Scholar
  17. 17.
    Gallivan GJ. FEES/FEESST and videotape recording: there’s more to this than meets the eye. Chest. 2002;122(5):1513–5.CrossRefPubMedGoogle Scholar
  18. 18.
    Dziewas R, Glahn J, Helfer C, Ickenstein G, Keller J, Ledl C, Lindner-Pfleghar B, Nabavi D, Prosiegel M, Riecker A, Lapa S, Stanschus S, Warnecke T, Busse O. Flexible endoscopic evaluation of swallowing (FEES) for neurogenic dysphagia: training curriculum of the German Society of Neurology and the German stroke society. BMC Med Educ. 2016;16:70. doi: 10.1186/s12909-016-0587-3.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Vu A, Farah CS. Narrow band imaging: clinical applications in oral and oropharyngeal cancer. Oral Dis. 2016;22(5):383–90. doi: 10.1111/odi.12430.CrossRefPubMedGoogle Scholar
  20. 20.
    Wu CH, Hsiao TY, Chen JC, Chang YC, Lee SY. Evaluation of swallowing safety with fiberoptic endoscope: comparison with videofluoroscopic technique. Laryngoscope. 1997;107(3):396–401.CrossRefPubMedGoogle Scholar
  21. 21.
    Onofri SM, Cola PC, Berti LC, da Silva RG, Dantas RO. Correlation between laryngeal sensitivity and penetration/aspiration after stroke. Dysphagia. 2014;29(2):256–61. doi: 10.1007/s00455-013-9504-7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  • Julie C. Nienstedt
    • 1
  • Frank Müller
    • 1
  • Almut Nießen
    • 1
  • Susanne Fleischer
    • 1
  • Jana-Christiane Koseki
    • 1
  • Till Flügel
    • 1
  • Christina Pflug
    • 1
    Email author
  1. 1.Department of Voice, Speech and Hearing Disorders, Center for Clinical NeurosciencesUniversity Medical Center Hamburg-EppendorfHamburgGermany

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