Videoendoscopic Swallowing Study (VESS)

A method of evaluating a person’s swallowing ability by means of a video-documented physical examination, looking from inside the throat. Also called the fiberoptic endoscopic evaluation of swallowing (FEES). The videoendoscopic swallowing study (VESS) is to be distinguished from the videofluoroscopic swallowing study (VFSS), which is an x-ray-based assessment.

How a VESS Works

To perform a VESS, a clinician uses a fiberoptic or distal-chip nasolaryngoscope. The clinician begins by examining the structure and function of the patient’s palate, tongue, pharynx, and larynx, including sensation, if desired. Next, to assess the patient’s swallowing capabilities and limitations, the clinician positions the tip of the nasolaryngoscope just below the nasopharynx and, looking downward into the throat, asks the patient to swallow a series of colored substances with a range of consistencies (e.g., blue-stained water, blue-stained applesauce, and orange-colored crackers).

As the patient swallows these substances, the clinician watches to see if any significant traces remain in or reappear in the space above, around, or within the larynx, rather than disappearing into the entrance to the esophagus. If significant traces remain in view, or if any material spills into the opening of the larynx or down the trachea, the patient may have presbyphagia. If significant traces initially disappear but then re-emerge upward from the esophageal entrance, the patient may have cricopharyngeal dysfunction, with or without a Zenker’s diverticulum.

Benefits of the Videoendoscopic Swallowing Study

This method has particular value for patients who are bedfast and cannot travel to the radiology suite, or for patients whose swallowing function is rapidly evolving (improving, usually), such as those recovering from a mild stroke. For clinicians experienced with this technique, VESS can also often be used with new patients complaining of dysphagia during the initial consultation as a robust and—depending on patient history—potentially stand-alone method of diagnosis and management.

Sometimes, the VESS findings, along with a patient history of solid food lodgment at the level of the cricoid cartilage or cricopharyngeus muscle, will indicate when VFSS should also be obtained to assess for possible cricopharyngeal dysfunction. Even in this latter circumstance, when VFSS is called upon to confirm a suspected diagnosis, VESS will have already oriented the examiner to the nature and severity of the problem. In most follow-up circumstances other than after cricopharyngeal myotomy, VESS is generally more efficient and inexpensive than VFSS.

What is the difference between VESS and VFSS?

VESS is a comprehensive, often stand-alone methodology patterned in many ways after the videofluoroscopic swallowing study (VFSS).

VFSS uses three consistencies of food material – liquid, puree, and solid – mixed with barium and administered under the supervision of a speech pathologist in the radiography suite of a hospital.

By contrast, VESS uses visual videoendoscopic imaging of the swallowing tract. The patient’s anatomy and neurological examination (palate, pharynx, and larynx) are first assessed in detail using various elicitation techniques. The presence or absence of retained saliva is next noted.

Finally, the patient is offered, in an appropriate sequence, water, pudding, and cracker each stained with food coloring to assess swallowing ability. When there is question about esophageal function, VFSS may also need to be done.

When VFSS has already been done, or when follow-up swallowing studies are needed, VESS typically is used as an alternative to VFSS.

VESS Assesses Equipment, Secretions, then Swallowing Ability

Part Ia: Palate elevates normally (1 of 7)

This man has symptoms of cricopharyngeus muscle dysfunction (CPD), with frequent lodgment of solid food (never soft or liquid material) at the level of mid-to-low neck. This VESS sequence demonstrates his propulsive or “pitcher” ability. Here in VESS part Ia, palate elevates normally (arrows). Left palate is not drooping and there is no deviation.

Part Ib: phonation (2 of 7)

In Part Ib of VESS, the patient makes voice, to prove normal movement and good closure of the vocal cords. In addition, no secretional pooling is seen in vallecula or pyriform sinuses.

Part Ic: High pitch elicited (3 of 7)

Part Ic: Very high pitch is elicited. Pharyngeal walls contract inward (arrows), closing the pyriform sinuses. Part Ia,b, and c (Photos 1, 2, and 3) verify that there is good function of swallowing equipment, i.e. palate, pharynx, and larynx (and tongue).

applesauce in pharyngeus — Part IIa: applesauce (4 of 7)

Part IIa: Blue-stained applesauce is first, because puree is the “easiest” material for the majority of patients, whatever their diagnosis. Here, one sees only minimal residue after several boluses are swallowed.

cracker in pharyngeus — Part IIb: cracker (5 of 7)

Part IIb: After an orange (cheese) cracker, lodgment in the vallecula, and…

Part IIb: continued (6 of 7)

…on the pharyngeal walls (arrows).

water in pharyngeus — Part IIc: water (7 of 7)

Part IIc: After several boluses of blue-stained water, all cracker is washed away and there is no blue staining or residue within the laryngeal vestibule, subglottis, or high trachea. Given this man’s CPD symptoms, VFSS may show a cricopharyngeus muscle bar, indicating incomplete relaxation of the upper esophageal sphincter.

Dysphagia / Delayed Swallow Reflex

Laryngopharynx (1 of 3)

Panoramic view of laryngopharynx before administering blue-stained applesauce.

Dysphagia / Delayed swallow reflex (2 of 3)

Same view after first bolus of blue-stained applesauce. The vallecula fills with material before the swallow “happens”—signifying a delayed swallow reflex.

Delayed swallow reflex — Hypopharyngeal pooling (3 of 3)

After several rapidly-administered boluses (to assess patient’s “limits”), note hypopharyngeal pooling, but none within the laryngeal vestibule.

The Cricopharyngeus Muscle Seen During Swallowing

This person struggles to swallow due to a combination of prior tongue cancer surgery decades ago, and longterm radiation effects. Solid foods are the most problematic, and so this sequence shows an attempt to swallow water stained with blue food coloring.

Swallowing crescent (1 of 5)

Panoramic view of the hypopharynx and larynx during breathing. E = epiglottis. Arrows point to the open vocal cords with triangular entrance to airway between them. Dotted line indicates the “swallowing crescent” including part of pyriform sinuses and post-arytenoid space.

Swallowing water (2 of 5)

Blue-stained water is collected in the “swallowing crescent” and about to enter the upper esophagus. The larynx is closed anteriorly (lower photo). The V marks the same post-arytenoid location in subsequent photos.

Cricopharyngeus muscle (3 of 5)

The larynx is coming forward, opening the way into the esophagus. The cricopharyngeus muscle is seen in the distance, marked with CPM.

Relaxed CPM (4 of 5)

With the blue water now passed into the esophagus, the partially relaxed sphincter is seen more clearly, again marked CPM.

Partially open esophagus due to A-CPD (5 of 5)

A closer view, showing only partially open esophageal entrance because of antegrade cricopharyngeus muscle dysfunction: it refuses to relax fully and this is part of the explanation for why this person cannot swallow solid foods through a less-than-half-opened sphincter.

Zenker’s Diverticulum

Postcricoid area (2 of 3)

Same view, a second later, as blue-stained applesauce emerges from the Zenker’s diverticulum upward (toward the camera) into the postcricoid area.

Reflux Into Hypopharynx, Characteristic of Cricopharyngeal Dysfunction

Vallecular Cysts don’t Disturb Swallowing—Except When They Do

Evaluation of function (2 of 4)

Palate, pharynx, and larynx function are all normal. There is no pooling of saliva in the hypopharynx.

Applesauce residue (3 of 4)

An organized ring of applesauce remains after trying to swallow blue-stained applesauce.

Water wash (4 of 4)

Water wash is very effective in clearing the applesauce away. Vallecular cysts are usually left alone; here, the plan is to remove it with the thulium laser and see if swallowing is restored.

Pill Lodgment Due to Swallowing Disability

Lodged pill (1 of 4)

This older woman swallowed a pill that lodged low in her throat. In spite of repeated swallows and attempts at expectoration, she couldn’t move it for many hours. On examination a few days later, this superficial ulceration is seen due to mild chemical burn. Note as well the redness of the left arytenoid and pyriform sinus (right of photo).

Trumpet maneuver (2 of 4)

At closer range, while having the patient perform a trumpet maneuver, a well-demarcated superficial ulcer is seen again.

VESS (3 of 4)

Administration of blue-stained applesauce during VESS shows that a partial reason for lodgment may be reduced propulsive strength, indicated by pooling of material in the vallecula.

Incomplete relaxation of CPD (4 of 4)

After sips of blue-stained water, note the fairly organized crescent of pooled water in the pyriform sinuses and post-arytenoid area. This can suggest a functional outlet obstruction caused by incomplete relaxation of the cricopharyngeus muscle (CPD).

Delayed Swallow Reflex: Compare Blue Applesauce and Blue Water

VESS (1 of 4)

During VESS, blue-stained applesauce falls down to the posterior base of tongue. If the swallowing reflex were normal, the patient would have swallowed before the applesauce arrived here.

Blue-stained water (3 of 4)

Here, blue-stained water is flowing into the right pyriform sinus (left of photo at arrow). Movement is rapid (note the blur) due to the low viscosity of water; there is less time to react and swallow than with applesauce, explaining why coughing on water is more common than purée or solid.

No residue (4 of 4)

Still, at the end of several boluses of applesauce and water, stained with blue food coloring, there is no stain or residue inside the entrance of the airway. The delayed swallowing reflex is a liability but without a risk of pneumonia.

Scarring Diverts Swallowed Materials Directly into the Larynx

Post tonsillectomy (1 of 4)

A young woman struggles to swallow after extensive cauterization of severe bleeding after tonsillectomy elsewhere. The arrows here show the path food and liquid should follow to get into the esophagus (opening indicated by flat oval).

Closer view (2 of 4)

Closer view shows that the epiglottis is tethered to base of tongue at the dotted line. Furthermore, the “ski jump” scar appears to be ready to divert swallowed material directly into the larynx ( arrow) rather than into the pyriform sinus at *.

chute into the larynx — The “chute” (3 of 4)

A closer view shows even better the “chute” into the larynx.

Abnormal diversion (4 of 4)

While swallowing blue-colored water, arrows indicate the normal path on the left (right of photo) and the abnormal diversion into the larynx on the right (left of photo). The patient manages, but must swallow carefully, especially since the epiglottis cannot invert since it is scarred to the base of tongue as shown in photo 2.

Skull Base Fracture and Vagus Nerve Injury—Note Pharynx Contraction and Impact on Swallowing

Palate branch of the vagus nerve (1 of 4)

This young woman sustained facial bone and skull base fracture during an auto accident. In this nasopharynx view, note that her right palate (left of photo) elevates fully (long arrow), while the left side only partially (short arrow). The palate branch of the vagus nerve is injured on the left (right of photo).

Pharynx branch of the vagus nerve (2 of 4)

At rest, the pharynx appears flat and symmetrical, but there is a question whether the midline may have migrated to the patient’s right (left of photo). The vagal branch to the pharynx is also injured on the left (right of photo)

Damage to left vagal nerve function (3 of 4)

By eliciting a very high-pitched voice, a pharynx contraction is recruited and now we can see that the pharyngeal wall pulls to the right (horizontal arrow) and the constrictor muscle squeezes inward only on the right (long arrow at left of photo). This confirms good right vagal function (left of photo) and damage on the left (not pictured).

Residue during swallowing test (4 of 4)

After eating a cracker and attempting to wash it away with water, the residue is primarily in the vallecula and left pyriform sinus. Arrows show how the pharynx can squeeze during swallowing in order to clear out the right pyriform sinus (left of photo). With no active muscle on the left (right of photo) to clear out the pyriform sinus, it pools food.

VESS in 6 Still Photos

Assessing the patient's swallowing — Assessing the patient’s swallowing (1 of 6)

Step 1 is assessment of the patient’s swallowing “equipment.” Here we see that the palate elevates symmetrically against the posterior pharyngeal wall.

Observing the pharynx (2 of 6)

The next step is to observe the pharynx squeeze with inferior constrictors bulging to surround the larynx. The vocal cords close fully.

Patient secretions (3 of 6)

Next is the assessment of patient secretions. This hypopharyngeal pooling of saliva (foamy bubbles) predicts that there will be similar pooling of swallowed food materials during the next step of VESS.

Pooling of swallowed pureed food (4 of 6)

As predicted, blue-stained applesauce (purée consistency) pools in the pyriform sinuses. There is no laryngeal soiling (penetration, aspiration).

Swallowing solids (5 of 6)

The next test is the cheese cracker (solid consistency). After swallowing, the residue is seen especially in the vallecula.

Residue after foods (6 of 6)

After several boluses of blue-stained water, a small amount remains in the pyriform sinuses and post-arytenoid area.

VESS (Videoendoscopic Swallow Study) Findings after Radiotherapy

narrowing of the pharyngeal wall from radiation scarring — Narrowed pharyngeal wall (1 of 7)

After radiation and chemotherapy for larynx cancer several years earlier. Note the dry secretions. There is narrowing of the pharyngeal wall (dotted line) due to radiation scarring.

Swallowing applesauce (2 of 7)

After the second bolus of blue-stained applesauce. The propulsive ability (“pitcher of swallowing”) is inadequate, leaving a lot of post-swallow residue.

cleaned esophagus with bits of blue applesauce — After sipping water (3 of 7)

After three sips of blue-stained water, much of the applesauce has been washed away.

Gravity aiding in swallowing (4 of 7)

Additional water washes nearly all of the residue in the “swallowing crescent” away–mostly by gravity as seen in the next photo.

Lifting larynx (5 of 7)

Each swallow looks like this. The pharynx “bird swallow” mechanism lifts larynx forward so that the swallowing crescent opens down to the cricopharyngeus muscle, indicated by double dotted lines. (PC = post-cricoid.)

A closer look (6 of 7)

At closer range, the cricopharyngeus muscle bulge is seen more clearly, along with the small opening into the esophagus.

Gravity aiding again in swallowing (7 of 7)

Blue-stained water flowing into the esophagus mostly by gravity.

Cervical Osteophytes do not by Themselves Seem a Major Impediment to Swallowing

Protruding osteophytes (1 of 2)

This 95 year-old man has large cervical osteophytes (bony proliferation due to arthritis). These osteophytes protrude into the pharynx (dotted lines). It would seem they would be a major impediment to swallowing.

Rapid swallowing (2 of 2)

After an initial test swallow, eight boluses of blue applesauce are administered rapidly. The purpose of this is to serve as a “stress test” so that we see his swallowing at its worst…But he has only a small amount of residue, and passes the test. Most individuals with cervical osteophytes are of advanced age. When swallowing is impaired, the explanation is usually more than just the osteophyte.

Aspiration, and Fountain of Returned Aspirate after Coughing

Salivary pooling (1 of 5)

This young man has a chromosome disorder. He has trouble swallowing but no history of pneumonia. The palate, pharynx, and larynx motor function is normal, but the salivary pooling seen here predicts what follows…

After applesauce (2 of 5)

After several boluses of blue-stained applesauce, there is significant pooling (residue), but nothing down at the level of the vocal cords.

After cheese cracker (3 of 5)

After chewing and swallowing a cheese cracker, a part is lodged in the vallecular.

After water (4 of 5)

During administration of blue-stained water, a large drip is seen falling downwards, directly into the laryngeal vestibule.

Cough expels the water from airway (5 of 5)

A moment later, a cough sprays the aspirated blue-stained water upwards and out of the airway.

Three Views of the Entrance to the Esophagus from far Away to Close-up

Closed esophagus (2 of 3)

A closer view. The esophagus is still not open in this view. Compare asterisk with prior and following photo.

Open Esophagus (3 of 3)

At the moment of a dry swallow, the esophagus opens as shown here. Again, the asterisks allow comparison with photos 1 and 2.

Video Overview

A method of evaluating a person’s swallowing ability by means of a video-documented physical examination, looking from inside the throat. Also called the fiberoptic endoscopic evaluation of swallowing (FEES).

VESS: An alternative and partner to the VFSS

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Videoendoscopic Swallowing Study (VESS)

How a VESS Works

Benefits of the Videoendoscopic Swallowing Study

What is the difference between VESS and VFSS?

VESS Assesses Equipment, Secretions, then Swallowing Ability

Part Ia: Palate elevates normally (1 of 7)

Part Ib: phonation (2 of 7)

Part Ic: High pitch elicited (3 of 7)

Part IIa: applesauce (4 of 7)

Part IIb: cracker (5 of 7)

Part IIb: continued (6 of 7)

Part IIc: water (7 of 7)

Dysphagia / Delayed Swallow Reflex

Laryngopharynx (1 of 3)

Dysphagia / Delayed swallow reflex (2 of 3)

Hypopharyngeal pooling (3 of 3)

The Cricopharyngeus Muscle Seen During Swallowing

Swallowing crescent (1 of 5)

Swallowing water (2 of 5)

Cricopharyngeus muscle (3 of 5)

Relaxed CPM (4 of 5)

Partially open esophagus due to A-CPD (5 of 5)

Zenker’s Diverticulum

Zenker’s diverticulum (1 of 3)

Postcricoid area (2 of 3)

Hypopharynx (3 of 3)

Reflux Into Hypopharynx, Characteristic of Cricopharyngeal Dysfunction

Reflux into hypopharynx (1 of 3)

Water flows into the swallowing crescent (2 of 3)

Larynx opens up (3 of 3)

Vallecular Cysts don’t Disturb Swallowing—Except When They Do

Vallecular cyst (1 of 4)

Evaluation of function (2 of 4)

Applesauce residue (3 of 4)

Water wash (4 of 4)

Pill Lodgment Due to Swallowing Disability

Lodged pill (1 of 4)

Trumpet maneuver (2 of 4)

VESS (3 of 4)

Incomplete relaxation of CPD (4 of 4)

Delayed Swallow Reflex: Compare Blue Applesauce and Blue Water

VESS (1 of 4)

Delayed swallow reflex (2 of 4)

Blue-stained water (3 of 4)

No residue (4 of 4)

Scarring Diverts Swallowed Materials Directly into the Larynx

Post tonsillectomy (1 of 4)

Closer view (2 of 4)

The “chute” (3 of 4)

Abnormal diversion (4 of 4)

Skull Base Fracture and Vagus Nerve Injury—Note Pharynx Contraction and Impact on Swallowing

Palate branch of the vagus nerve (1 of 4)

Pharynx branch of the vagus nerve (2 of 4)

Damage to left vagal nerve function (3 of 4)

Residue during swallowing test (4 of 4)

VESS in 6 Still Photos

Assessing the patient’s swallowing (1 of 6)

Observing the pharynx (2 of 6)

Patient secretions (3 of 6)

Pooling of swallowed pureed food (4 of 6)

Swallowing solids (5 of 6)

Residue after foods (6 of 6)

VESS (Videoendoscopic Swallow Study) Findings after Radiotherapy

Narrowed pharyngeal wall (1 of 7)

Swallowing applesauce (2 of 7)

After sipping water (3 of 7)

Gravity aiding in swallowing (4 of 7)

Lifting larynx (5 of 7)

A closer look (6 of 7)

Gravity aiding again in swallowing (7 of 7)

Cervical Osteophytes do not by Themselves Seem a Major Impediment to Swallowing

Protruding osteophytes (1 of 2)

Rapid swallowing (2 of 2)

Aspiration, and Fountain of Returned Aspirate after Coughing

Salivary pooling (1 of 5)

After applesauce (2 of 5)

After cheese cracker (3 of 5)

After water (4 of 5)

Cough expels the water from airway (5 of 5)

Three Views of the Entrance to the Esophagus from far Away to Close-up