Differential diagnosis of stridor in the newborn: Guidelines for a time-efficient and cost-effective evaluation

Stridor is an abnormal respiratory noise that usually indicates the presence of a fixed and/or dynamic obstruction of the upper airway. Stridor in a neonate is particularly concerning because it may indicate a severe lesion that can compromise airway patency in an infant with little tolerance for impaired ventilation or oxygenation. We will discuss the differential diagnosis of stridor in neonates using a time and cost-efficient strategy for evaluation. We will discuss the diagnostic tests that are most appropriate for neonates with noisy breathing by emphasizing the use of physical examination and history to determine the location(s) of the airway obstruction(s) and to narrow the differential diagnosis. A focused history centers on perinatal issues and the onset and progression of stridor. We will discuss the relevant associated signs and symptoms, as well as the changes in stridor while an infant is awake, feeding, or sleeping. We will address the most appropriate use of airway endoscopy in the ambulatory setting and in the operating room. Fiberoptic laryngoscopy in awake neonates is perhaps the most useful endeavor for evaluating newborn infants who have stridor. Radiologic tests will be discussed, with a renewed focus on reducing exposure to ionizing radiation by selecting the correct imaging modality and avoiding studies that are not useful.