Is image interpretation in drug-induced sleep endoscopy that reliable?

  • Sophie BartierEmail author
  • Marc Blumen
  • Frédéric Chabolle
ENT • Original Article



Previous studies have assessed drug-induced sleep endoscopy (DISE) as an interobserver reliable exam, with a learning curve effect. The objective was to check its assumed interobserver agreement and variability of between two groups of experienced and inexperienced French ENT physicians.


Prospective study. Seventy-six French ENT physicians (69 inexperienced in DISE and seven experienced) observed seven DISE videos. They were asked to determine the level(s), the configuration, and the degree of collapse, according to the VOTE classification. Specific and global agreements using the Fleiss’ Kappa coefficient (k) were calculated.


The interobserver agreement varied from poor to good in determining the level; the best agreement being found for the oropharynx (global agreement = 0.82 and k = 0.6 in the experienced group, global agreement = 0.87 and k = 0.7 in the inexperienced group), followed by the soft palate and the larynx; the worst agreement being found for the tongue base (k = 0.29 in the experienced group and k = 0.38 in the inexperienced group). The agreement for the configuration and the degree of collapse was moderate except for the tongue base where the concordance was poor. In both groups, agreement was at best good without any statistically significant difference between the two levels of experience groups.


Even in a French ENT Sleep Experts group, DISE appears to be a technique with a limited interobserver agreement in the detection of obstructive sites, without any learning curve effect. In its current state, DISE interpretation may not be totally reliable.


Drug-induced sleep endoscopy Obstructive sleep apnea Reliability VOTE classification 



Continuous positive airway pressure


Drug-induced sleep endoscopy


Ear nose throat


Kappa coefficient


Obstructive sleep apnea


Respiratory Event Index


target-controlled infusion



All the authors thank the participants in the study as well as the office of the French ENT Sleep Association (AFSORL) for the organization of the conference that allowed the study. We thank the physicians that provided the DISE videos: Dr. Olivier Gallet de Santerre, Dr. Xavier Dufour, Dr. Frédéric Chalumeau, Dr. Pierre Jean Monteyrol, and Dr. Laurent Yona. We also thank Ms Elodie Féliot, Biostatistics Department at Lariboisière Hospital, Paris, for her statistical calculations.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    AASM (1999) Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. The Report of an American Academy of Sleep Medicine Task Force. Sleep 22:667–689CrossRefGoogle Scholar
  2. 2.
    Qaseem A, Holty J-EC, Owens DK et al (2013) Management of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med 159:471–483. CrossRefPubMedGoogle Scholar
  3. 3.
    Vanderveken OM (2013) Drug-induced sleep endoscopy (DISE) for non-CPAP treatment selection in patients with sleep-disordered breathing. Sleep Breath 17:13–14. CrossRefPubMedGoogle Scholar
  4. 4.
    Katsantonis G (2008) The management of obstructive sleep apnea in adults. Mo Med 105:262–266PubMedGoogle Scholar
  5. 5.
    Blumen MB, Latournerie V, Bequignon E et al (2015) Are the obstruction sites visualized on drug-induced sleep endoscopy reliable? Sleep Breath 19:1021–1026. CrossRefPubMedGoogle Scholar
  6. 6.
    Croft CB, Pringle M (1991) Sleep nasendoscopy: a technique of assessment in snoring and obstructive sleep apnoea. Clin Otolaryngol 16:504–509CrossRefGoogle Scholar
  7. 7.
    Rabelo FAW, Braga A, Küpper DS et al (2010) Propofol-induced sleep: polysomnographic evaluation of patients with obstructive sleep apnea and controls. Otolaryngol--Head Neck Surg 142:218–224. CrossRefPubMedGoogle Scholar
  8. 8.
    Rodriguez-Bruno K, Goldberg AN, McCulloch CE, Kezirian EJ (2009) Test-retest reliability of drug-induced sleep endoscopy. Otolaryngol--Head Neck Surg 140:646–651. CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Soares D, Sinawe H, Folbe AJ et al (2012) Lateral oropharyngeal wall and supraglottic airway collapse associated with failure in sleep apnea surgery. The Laryngoscope 122:473–479. CrossRefPubMedGoogle Scholar
  10. 10.
    Vroegop AV, Vanderveken OM, Boudewyns AN et al (2014) Drug-induced sleep endoscopy in sleep-disordered breathing: report on 1,249 cases. The Laryngoscope 124:797– 802. CrossRefGoogle Scholar
  11. 11.
    Charakorn N, Kezirian EJ (2016) Drug-induced sleep endoscopy. Otolaryngol Clin North Am 49:1359–1372. CrossRefGoogle Scholar
  12. 12.
    Berry S, Roblin G, Williams A et al (2005) Validity of sleep nasendoscopy in the investigation of sleep related breathing disorders. The Laryngoscope 115:538–540. CrossRefPubMedGoogle Scholar
  13. 13.
    Steinhart H, Kuhn-Lohmann J, Gewalt K et al (2000) Upper airway collapsibility in habitual snorers and sleep apneics: evaluation with drug-induced sleep endoscopy. Acta Otolaryngol (Stockh) 120:990–994CrossRefGoogle Scholar
  14. 14.
    Marais J (1998) The value of sedation nasendoscopy: a comparison between snoring 18 and non-snoring patients. Clin Otolaryngol 23:74–76CrossRefGoogle Scholar
  15. 15.
    Sadaoka T, Kakitsuba N, Fujiwara Y et al (1996) The value of sleep nasendoscopy in the evaluation of patients with suspected sleep-related breathing disorders. Clin Otolaryngol 21:485–489CrossRefGoogle Scholar
  16. 16.
    Vroegop AVMT, Vanderveken OM, Wouters K et al (2013) Observer variation in drug-induced sleep endoscopy: experienced versus nonexperienced ear, nose, and throat surgeons. Sleep 36:947–953. CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Carrasco-Llatas M, Zerpa-Zerpa V, Dalmau-Galofre J (2016) Reliability of druginduced sedation endoscopy: interobserver agreement. Sleep Breath 21:173–179. CrossRefPubMedGoogle Scholar
  18. 18.
    Kezirian EJ, White DP, Malhotra A et al (2010) Interrater reliability of drug-induced sleep endoscopy. Arch Otolaryngol Head Neck Surg 136:393–397. CrossRefPubMedGoogle Scholar
  19. 19.
    Kezirian EJ, Hohenhorst W, de Vries N (2011) Drug-induced sleep endoscopy: the VOTE classification. Eur Arch Oto-Rhino-Laryngol 268:1233–1236. CrossRefGoogle Scholar
  20. 20.
    Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174. CrossRefGoogle Scholar
  21. 21.
    De Vito A, Carrasco Llatas M, Ravesloot MJ et al (2018) European position paper on drug-induced sleep endoscopy: 2017 Update. Clin Otolaryngol 43:1541–1552. CrossRefPubMedGoogle Scholar
  22. 22.
    Altintaş A, Olgun B, Yegin Y et al (2017) Interobserver consistency of drug-induced sleep endoscopy in diagnosing obstructive sleep apnea using a VOTE classification system. J Craniofac Surg 29:e140–e143. CrossRefGoogle Scholar
  23. 23.
    de Quadros LG, Galvão Neto MDP, Campos JM et al (2017) Validation of a new method for the endoscopic measurement of post-bariatric gastric outlet using a standard guidewire: an observer agreement study. BMC 10:13.
  24. 24.
    Stoeckli SJ, Huisman TAGM, Seifert B, Martin-Harris BJW (2003) Interrater reliability of videofluoroscopic swallow evaluation. Dysphagia 18:53–57. CrossRefPubMedGoogle Scholar
  25. 25.
    Hsu Y-S, Jacobowitz O (2017) Does Sleep endoscopy staging pattern correlate with outcome of advanced palatopharyngoplasty for moderate to severe obstructive sleep apnea? J Clin Sleep Med 13:1137–1144. CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    De Vito A, Carrasco Llatas M, Vanni A, et al (2014) European position paper on druginduced sedation endoscopy (DISE). Sleep Breath18:453–465. CrossRefGoogle Scholar
  27. 27.
    Vicini C, De Vito A, Benazzo M et al (2012) The nose oropharynx hypopharynx and larynx (NOHL) classification: a new system of diagnostic standardized examination for 19 OSAHS patients. Eur Arch Oto-Rhino-Laryngol 269:1297–1300. CrossRefGoogle Scholar
  28. 28.
    Gillespie MB, Reddy RP, White DR et al (2013) A trial of drug-induced sleep endoscopy in the surgical management of sleep-disordered breathing. The Laryngoscope 123:277–282. CrossRefPubMedGoogle Scholar
  29. 29.
    Carrasco-Llatas M, Zerpa-Zerpa V (2017) Response to reliability of drug-induced sedation endoscopy: a methodological issue. Sleep Breath 21:779–780. CrossRefPubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Otolaryngology, Head and Neck surgeryFoch HospitalSuresnesFrance
  2. 2.Université de Versailles Saint-Quentin en Yvelines, UFR de médecine Paris Ouest Saint-Quentin-en-YvelinesGuyancourtFrance

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