degrees of distress Physicians must determine how much the obstruction is affecting the baby and if emergency airway management is needed CLINICAL PEARLS AND PITFALLS Neonates are obligate nasal breathers until weeks of life Any nasal obstruction can cause respiratory distress during this period The ability to successfully pass a nasogastric tube bilaterally rules out choanal atresia Natal teeth can be an aspiration risk If loose, they should be extracted Cysts or masses in the neck should be immediately assessed for acute airway obstruction Nasal Obstruction Neonates are obligate nasal breathers up to to weeks of age Any nasal obstruction causing bilateral mucosal swelling will cause significant symptoms of obstruction and respiratory distress This is commonly seen in infants with upper respiratory tract infections Simple nasal obstruction should be differentiated from unilateral and bilateral choanal atresia Bilateral choanal atresia occurs in in 7,000 live births Associated anomalies such as CHARGE syndrome (C oloboma, H eart disease, choanal A tresia, R etarded development, G enital hypoplasia, E ar anomalies with hearing loss) occur in 20% to 50% of neonates with bilateral choanal atresia Unilateral atresia is more common than bilateral involvement Symptoms of bilateral choanal atresia vary from mild cyanosis during feeds to severe hypoxia and respiratory distress The onset is shortly after birth Cyanosis occurs when the mouth is completely occluded during feeds and improves with crying Inability to pass a 6F catheter bilaterally through the nares is suspicious Smaller soft catheters may coil in the nares and give a false impression of patency Visualizing or palpating the nasogastric tube in the mouth will also confirm passage and patency Clinicians should also avoid unnecessary mucosal swelling by repeated forceful trials since this will also make it difficult to rule out obstruction Unilateral choanal atresia presents with intermittent nasal obstruction which may pass unnoticed at birth Bedside endoscopic nasal examination can be performed by trained personnel or otolaryngologist A CT or MRI scan will confirm presence of choanal atresia, differentiate unilateral from bilateral, differentiate between choanal stenosis and atresia, and determine whether the lesion is boney or membranous ( Fig 96.30 ) MRI minimizes radiation exposure