Differentiating upper- from lower-airway compromise in the neonate may be difficult. Knowledge of the multiple problems that affect the airway and an organized approach to assessment aid in determining the site(s) of respiratory compromise. Although endoscopy provides information about the status of the upper airway, the length of time elapsed from extubation may affect the predictive value of observations made at endoscopy. The otolaryngologist should avoid recommending surgical intervention for relief of upper-airway compromise when the major cause of respiratory insufficiency is in the lower airway. Conversely, appropriate surgical intervention at the appropriate time may obviate the need for a tracheotomy. Lastly, if the prognosis is such that continued intubation is necessary and may lead to laryngeal or subglottic damage, a tracheotomy should be performed.