Practice Variation in Flexible Endoscopic Evaluation of Swallowing (FEES): An International Survey

Flexible endoscopic evaluation of swallowing (FEES) is a cornerstone of instrumental dysphagia assessment, yet substantial practice variation has been documented across clinical settings. This study aimed to characterize variation in FEES protocols and examine associations between clinician and professional characteristics, practice patterns, and confidence in interpreting clinical findings. An online survey was completed by 109 professionals with FEES experience. The final analytic sample included 97 participants. The survey assessed demographic and professional background, protocol components, examination duration, and self-rated confidence in clinical judgements. Substantial heterogeneity was found across FEES protocol components, including inconsistent incorporation of sensory testing, variable dye use, and diverse rating scale adoption. The Penetration-Aspiration Scale was used by 98.9% of respondents, while other scales showed lower adoption rates. Confidence was highest for judging aspiration presence and lowest for aspiration depth. Greater FEES-specific experience was associated with shorter examination duration (p = 0.03), but neither years of experience nor education level significantly predicted overall confidence in judgment. Physician status and higher education were significantly associated with performing formal sensory testing. FEES is implemented with considerable variability in clinical practice. Confidence in judgment appears to be influenced by the complexity of the clinical finding and the availability of structured rating tools rather than by experience or education alone. These findings support the need for clearer definition of core protocol components, development of standardized tools for complex swallowing parameters, and systematic evaluation of training models.