Detection of Swallowing Abnormalities in Pediatric FEES Recordings Using Rule-Based and Model-Based Methods

Pediatric swallowing dysfunction (SwD) poses serious health risks, including aspiration, malnutrition, and recurrent respiratory infections, making early and accurate diagnosis essential for preventing long-term sequelae such as chronic lung disease and growth failure. Fiberoptic endoscopic evaluation of swallowing (FEES) is widely used for direct visualization of the swallowing mechanism in children, offering advantages over fluoroscopy such as bedside accessibility and radiation-free imaging. During FEES, patients swallow green-dyed liquid with an endoscope positioned in the throat. Interpreting FEES recordings is a subjective, time-consuming process that requires specialized expertise. Automated, objective analysis tools would be useful to support clinical decision-making. In this study, we propose a hybrid framework for classifying pediatric FEES recordings as normal or abnormal. The approach combines a rule-based analysis which detects the green-tinted swallowed liquid, with a transformer-based deep learning model. Frames are first filtered using a Siamese network to exclude irrelevant or low-quality frames, followed by quantification of the green frame ratio based on frames containing green patches. A confidence-guided decision strategy classifies clear-cut cases via thresholding, while delegating uncertain cases to the deep learning model for further evaluation. Evaluation on 142 pediatric FEES videos (45 normal and 97 with abnormalities) showed that the hybrid approach outperformed both the deep learning and rule-based methods individually, achieving 89.4% accuracy, 96.6% precision, and 93.3% specificity for aspiration. Our results indicate that by combining rule-based and deep learning strategies, we could reliably detect swallowing abnormalities from pediatric FEES videos with accuracies comparable to experts.