When should a neonate with disordered breathing be referred to Ear, Nose, and Throat (ENT) specialist?

When to Refer a Neonate with Disordered Breathing to ENT

A neonate with disordered breathing should be referred to ENT when presenting with unexplained respiratory distress requiring oxygen for more than 24 hours, persistent stridor, chronic nasal congestion, suspected airway malacia, or failure to wean from respiratory support as expected. 1, 2

Urgent ENT Referral Indications

Severe Respiratory Distress

• SpO₂ < 93% despite appropriate interventions 1
• Presence of severe respiratory distress signs (grunting, nasal flaring, head nodding, tracheal tugging, intercostal retractions) 1
• Unexplained neonatal respiratory distress requiring supplemental oxygen for >24 hours in term infants 1

Upper Airway Concerns

• Persistent stridor or noisy breathing unresponsive to initial management 3
• Suspected vocal cord paralysis (especially after PDA ligation) 1, 2
• Inability to pass nasal catheters or suspected choanal atresia/stenosis 4
• Persistent nasal obstruction in an obligate nasal breather 4

Non-Urgent ENT Referral Indications

Persistent Symptoms

• Early-onset, year-round nasal congestion 1
• Chronic wet cough not responding to appropriate therapy 1
• Recurrent wheezing not responsive to bronchodilator trials 1
• Failure to wean from oxygen therapy or ventilatory support as expected 1

Associated Conditions

• Suspected airway malacia (tracheobronchomalacia) 2
• Congenital rib anomalies with respiratory symptoms 2
• Situs inversus or other laterality defects with respiratory symptoms (consider Primary Ciliary Dyskinesia) 1
• Lobar collapse on imaging with persistent respiratory symptoms 1

Evaluation Prior to ENT Referral

Essential Assessments

• Pulse oximetry to document oxygen saturation levels 1
• Chest radiography to evaluate for structural abnormalities 2, 5
• Trial of bronchodilator therapy if wheezing is present to assess response 1
• Overnight or 24-hour oximetry if sleep-disordered breathing is suspected 1

Special Considerations

• For neonates with feeding difficulties and respiratory symptoms, consider a swallow evaluation (VFSS) before or concurrent with ENT referral 1
• For neonates with persistent apnea, intermittent desaturation, or bradycardia at >40 weeks' postmenstrual age, consider polysomnography 1

Clinical Pearls and Pitfalls

Important Clinical Pearls

• Neonates are obligate nasal breathers; even subtle nasal obstruction can cause significant respiratory distress 4
• The combination of situs inversus, lobar collapse, or oxygen need for >2 days has 87% sensitivity and 96% specificity for Primary Ciliary Dyskinesia 1
• Not all noisy breathing is due to laryngomalacia; consider extrinsic compression from masses 3

Common Pitfalls

• Assuming passage of small nasal catheters rules out significant nasal obstruction 4
• Attributing all neonatal respiratory distress to common conditions (TTN, RDS) without considering anatomical airway abnormalities 6, 5
• Delaying ENT referral for persistent symptoms after treating for presumed infectious causes 5
• Failing to consider airway endoscopy for unexplained chronic respiratory symptoms 1, 2

By following these guidelines for ENT referral, clinicians can ensure timely diagnosis and management of airway abnormalities in neonates with disordered breathing, potentially improving long-term respiratory outcomes and quality of life.