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PubMed This is a summary of 20 peer-reviewed journal articles Updated
Pediatrics

Recognizing and Diagnosing Choanal Atresia

At a Glance

Choanal atresia is a nasal blockage in newborns that disrupts breathing and feeding. It is diagnosed through symptoms like paradoxical cyanosis (turning blue when resting but pink when crying), bedside catheter tests, and a CT scan, which is the gold standard for surgical planning.

Diagnosing choanal atresia involves a combination of observing physical symptoms and using advanced imaging to “see” the internal structure of your baby’s nose. Because the blockage is hidden deep inside, doctors use specific tests to confirm its presence and plan for treatment.

The Challenge of Being an “Obligate Nasal Breather”

As mentioned earlier, for the first 6 weeks (and often up to 5 or 6 months) of life, newborns are obligate nasal breathers [1][2]. Their bodies are biologically programmed to breathe almost exclusively through their nose, allowing them to breathe and eat at the same time [3][4]. When the nasal passage is blocked, this natural rhythm is disrupted, making simple tasks like sleeping or feeding a major struggle [5].

How Symptoms Differ

The way the condition presents depends largely on whether one or both sides are blocked.

Bilateral (Both Sides)

This is typically caught immediately at birth because it is a life-threatening emergency [1]. You may see:

  • Paradoxical Cyanosis: This is a classic sign where the baby turns blue while quiet or sleeping but turns pink again when they cry [6]. Crying forces the baby to breathe through their mouth, temporarily bypassing the nasal blockage [7].
  • Severe Respiratory Distress: The baby may appear to be working very hard to move air [8].

Unilateral (One Side)

This diagnosis is often delayed for months or even years because the baby can still breathe through the open side [9][10]. Symptoms include:

  • Persistent Nasal Discharge: A thick, mucoid discharge (rhinorrhea) that only comes from one nostril [10][11].
  • One-Sided Obstruction: The child may always seem “stuffy” on only one side [12].
  • Confusion with Other Issues: Because it is less dramatic, it is sometimes mistaken for a common cold or a nasal foreign body (something stuck in the nose) [13].

The Diagnostic Process

If a doctor suspects a blockage, they will follow a step-by-step process to confirm it.

  1. The Catheter Test: At the bedside, a doctor will attempt to pass a small, flexible tube (suction catheter) through each nostril [14]. If the tube cannot reach the back of the throat, it suggests a physical blockage [1].
  2. Nasopharyngoscopy: A doctor uses a tiny, flexible camera (an endoscope) to look directly into the nasal passage [15]. This allows them to see the wall of tissue—the atretic plate—blocking the way [16].
  3. CT Scan (The Gold Standard): This is the most important tool for surgical planning [16]. A CT scan provides a detailed “map” of the blockage, showing:
    • Whether the wall is made of bone, membrane, or both [17].
    • The thickness of the vomer (the bone that divides the two sides of the nose), which is often wider than normal in cases of choanal atresia [17][18].
    • The exact dimensions of the nasal cavity to guide the surgeon’s tools [17].

Other Conditions to Rule Out

The medical team must also distinguish choanal atresia from other structural issues, such as:

  • Nasal Pyriform Aperture Stenosis (NPAS): A narrowing at the very front of the nose caused by bone overgrowth [13][19].
  • Dacryocystoceles: Fluid-filled cysts near the tear ducts that can block the airway [13].
  • Midnasal Stenosis: Narrowing in the middle section of the nasal passage [13].

By using a CT scan and direct visualization, your care team can accurately identify the blockage and differentiate it from these other conditions, ensuring your baby receives the correct treatment plan [20].

Common questions in this guide

What are the signs of bilateral choanal atresia?
Bilateral choanal atresia is a life-threatening emergency often caught right at birth. The classic sign is paradoxical cyanosis, where a baby turns blue while resting or sleeping but turns pink again when they cry and breathe through their mouth.
Why does my baby only have nasal discharge from one nostril?
Persistent, thick discharge from just one nostril is a common sign of unilateral choanal atresia. Because the baby can still breathe through the open side, this one-sided blockage is sometimes mistaken for a common cold or something stuck in the nose.
Why is it so hard for my baby to feed if their nose is blocked?
Newborns are obligate nasal breathers, meaning their bodies are biologically programmed to breathe almost exclusively through their noses. A blocked nasal passage disrupts this natural rhythm, forcing them to stop frequently to take breaths through their mouth while eating.
How do doctors test a baby for choanal atresia?
Doctors typically start with a bedside catheter test, attempting to pass a small flexible tube through each nostril. If the tube cannot reach the back of the throat, they will use a tiny camera called an endoscope to look inside and confirm the blockage.
Why is a CT scan needed for a blocked nasal passage?
A CT scan is the gold standard for diagnosing choanal atresia because it provides a detailed map of the blockage. It shows whether the blockage is made of bone or membrane and gives exact dimensions to help the surgeon plan the best treatment.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Why was my baby unable to pass the nasal catheter test, and what does that tell us about the blockage?
  2. 2.How does the CT scan help you decide which surgical technique to use?
  3. 3.What specifically did the CT scan show about the thickness of the vomer bone?
  4. 4.Can you show me on the nasopharyngoscopy images where the blockage begins?
  5. 5.Are there other structural issues, like NPAS, that you also looked for during the exam?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (20)
  1. 1

    Bilateral choanal atresia diagnosed in a 3-month-old female baby: a case report.

    Abraham ZS, Kahinga AA

    Annals of medicine and surgery (2012) 2023; (85(4)):1227-1230 doi:10.1097/MS9.0000000000000484.

    PMID: 37113842
  2. 2

    CT findings of congenital neonatal pyriform aperture stenosis.

    Sidek HAB, Teh YG, Tangaperumal A, et al.

    Oxford medical case reports 2021; (2021(5)):omab018 doi:10.1093/omcr/omab018.

    PMID: 34055355
  3. 3

    Successful Noninvasive Respiratory Management of an Infant with Bilateral Choanal Atresia and a Supernumerary Nostril Located on the Columella by a Mouthpiece: A Case Report.

    Nakamura N, Kakita H, Takagi M, et al.

    The American journal of case reports 2023; (24()):e939642 doi:10.12659/AJCR.939642.

    PMID: 37357428
  4. 4

    A Case Report of Late Diagnosis of Bilateral Choanal Atresia.

    ALaryani RA, Alshammari J, Alshiha WS

    Cureus 2021; (13(8)):e17530 doi:10.7759/cureus.17530.

    PMID: 34471587
  5. 5

    Newborn nasal obstruction: Rare anatomical causes to consider.

    Asensi-Diaz M, Lowy Benoliel A, Pasamontes Pingarron JA, et al.

    Acta otorrinolaringologica espanola 2025; (76(6)):512279 doi:10.1016/j.otoeng.2025.512279.

    PMID: 40945678
  6. 6

    Congenital and Acquired Choanal Atresia: A Comprehensive Case Series on the Diagnosis and Contemporary Management.

    Gupta V, Raj P, Gupta DK, et al.

    Indian journal of otolaryngology and head and neck surgery : official publication of the Association of Otolaryngologists of India 2025; (77(8)):3206-3212 doi:10.1007/s12070-025-05623-0.

    PMID: 40727218
  7. 7

    Congenital bilateral nasal obstruction in neonate: Case report with review of literature for congenital nasal pyriform aperture stenosis (CNPAS) and differential diagnosis and management.

    Satpathy A, Dasgupta A, Mohan NVK, Dutta C

    National journal of maxillofacial surgery 2024; (15(2)):323-326 doi:10.4103/njms.njms_49_23.

    PMID: 39234131
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    Bilateral congenital choanal atresia in a preterm neonate - a rare neonatal emergency: A case report and review of literature.

    Zaidi A, Dey AC, Sabra O, James J

    Medical journal, Armed Forces India 2024; (80(1)):115-118 doi:10.1016/j.mjafi.2021.09.011.

    PMID: 38261804
  9. 9

    Bilateral Choanal Atresia in 24 Years Old Woman: A Case Report.

    Easa SH, Selim AN, Elswaby ES, Elbakry AM

    Indian journal of otolaryngology and head and neck surgery : official publication of the Association of Otolaryngologists of India 2024; (76(5)):4784-4787 doi:10.1007/s12070-024-04848-9.

    PMID: 39376437
  10. 10

    Late-diagnosed bilateral congenital choanal atresia in adulthood: a case report.

    Abboud F, Haddad S, Ibrahim G, et al.

    Journal of surgical case reports 2026; (2026(2)):rjag090 doi:10.1093/jscr/rjag090.

    PMID: 41727247
  11. 11

    Choanal stenosis post radiotherapy for nasopharyngeal carcinoma: about an endoscopic management.

    Lakhdar Y, Rochd S, Elbouderkaoui M, et al.

    The Pan African medical journal 2019; (34()):111 doi:10.11604/pamj.2019.34.111.18968.

    PMID: 31934253
  12. 12

    Bilateral Choanal Atresia in an Adolescent Female: A Rare Case Report.

    Legesse TK, Gellaw WL, Birhanu W, Zinaye A

    International medical case reports journal 2023; (16()):103-107 doi:10.2147/IMCRJ.S403272.

    PMID: 36880054
  13. 13

    Nasal Obstruction in the Infant.

    Frank S, Schoem SR

    Pediatric clinics of North America 2022; (69(2)):287-300 doi:10.1016/j.pcl.2021.12.002.

    PMID: 35337540
  14. 14

    Late Diagnosis of Bilateral Choanal Atresia: A Case Report of a Nine-Year-Old Girl.

    Foma W, Bissa H, Adam S, et al.

    Cureus 2022; (14(7)):e27203 doi:10.7759/cureus.27203.

    PMID: 36039226
  15. 15

    [Operative technique and follow-up effect of endoscopic congenital choanal atresia and dilatation].

    Deng HY, Gao XQ, Guo YF

    Lin chuang er bi yan hou tou jing wai ke za zhi = Journal of clinical otorhinolaryngology head and neck surgery 2019; (33(4)):367-370 doi:10.13201/j.issn.1001-1781.2019.04.019.

    PMID: 30970412
  16. 16

    [Clinical Management of Choanal Atresia].

    Maas AP, Strieth S, Send T

    Laryngo- rhino- otologie 2024; (103(1)):25-34 doi:10.1055/a-2160-2777.

    PMID: 37726020
  17. 17

    Nasal Cavity CT Imaging Contribution to the Diagnosis and Treatment of Choanal Atresia.

    Šebová I, Vyrvová I, Barkociová J

    Medicina (Kaunas, Lithuania) 2021; (57(2)) doi:10.3390/medicina57020093.

    PMID: 33494264
  18. 18

    Infant Midnasal Stenosis: Reliability of Nasal Metrics.

    Graham ME, Loveridge KM, Pollard SH, et al.

    AJNR. American journal of neuroradiology 2019; (40(3)):562-567 doi:10.3174/ajnr.A5980.

    PMID: 30765383
  19. 19

    Neonatal Nasal Obstruction: A Comprehensive Analysis of Our 20 Years' Experience.

    Shivnani D, Kobal S, Kobal M, et al.

    Indian journal of otolaryngology and head and neck surgery : official publication of the Association of Otolaryngologists of India 2024; (76(3)):2490-2501 doi:10.1007/s12070-024-04537-7.

    PMID: 38883526
  20. 20

    Association of Piriform Aperture Dimensions, Nasal Floor Asymmetry and Nasal Length With VAS and NOSE Score in Patients Planned for Septo(rhino)Plasty.

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This page is for informational purposes only and does not replace professional medical advice. Always consult your pediatrician or specialist immediately if you suspect your baby has breathing or feeding difficulties.

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