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RATIONALE: Fiberoptic flexible laryngoscopy (FFL) is the diagnostic procedure of choice in patients with laryngomalacia. Two techniques can be applied, either when the infant is awake or using anesthesia/sedation. The choice of technique may effect the diagnosis. STUDY OBJECTIVES: To compare the two techniques for diagnosing laryngomalacia. PATIENTS AND INTERVENTIONS: A total of 42 infants who underwent awake fiberoptic laryngoscopy for congenital stridor, in whom either laryngomalacia was diagnosed or no cause for stridor was found, underwent a repeat laryngoscopy using anesthesia/sedation. The 84 video recordings of the supraglottic portions were copied onto a videotape along with 25 recordings of normal upper airways without stridor and 31 duplicate cases with stridor. A total of 140 recordings was mixed at random on a videotape. Sound was not included. MEASUREMENTS: Three investigators (Y.S., J.B.A., and A.D.) independently scored each recording using a laryngomalacia scoring system (scoring range, 0 to 8). RESULTS: A threshold score of 2 was the optimal cutoff point for discriminating laryngomalacia from normal condition. The awake technique (WT) missed three cases of laryngomalacia and overdiagnosed one healthy control subject. The anesthesia technique was superior with a sensitivity of 100%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 100% compared with 93%, 92%, 97%, and 79%, respectively, for the WT. CONCLUSIONS: The diagnosis of laryngomalacia with FFL is more accurate using anesthesia/sedation. The WT may be appropriate for screening or for patients with mild cases having a characteristic presentation. [ABSTRACT FROM AUTHOR]