Point of Care Ultrasound Versus Neck Radiography for Laryngotracheal Stenosis: Complementary Roles in a Resource Limited Triage Pathway

Methods

This prospective diagnostic accuracy study was conducted at a South African tertiary referral centre between 1 January 2023 and 31 December 2025. Consecutive patients aged ≥12 years with suspected LTS (N=148) underwent point-of-care ultrasound (POCUS) using a handheld device (Butterfly iQ+), standardized anteroposterior and lateral soft-tissue neck radiography (XR), and computed tomography (CT) as the reference standard within a 24-hour interval.

Primary outcomes were sensitivity and specificity for detecting clinically significant LTS (≥50% luminal narrowing). Secondary outcomes included area under the receiver operating characteristic curve (AUC), likelihood ratios, and diagnostic performance stratified across six distinct anatomical regions (glottis, cricoid cartilage, cervical trachea at the thyroid isthmus, cervical trachea below the isthmus, thoracic trachea at the thoracic inlet, and thoracic trachea below the inlet) using transverse and anteroposterior (AP) planes, yielding 11 predefined measurements.

Results: Among 148 participants (mean age 38.2 years, 77 [52.0%] male), CT-confirmed LTS prevalence was 66.9% (99/148). Both modalities demonstrated high overall accuracy: XR sensitivity 93.9% (95% CI, 87.3–97.7%), specificity 98.0% (89.1–99.9%), AUC 0.959; POCUS sensitivity 91.9% (84.7–96.4%), specificity 93.9% (83.1–98.7%), AUC 0.929 (P=0.178 for difference). Performance varied substantially by anatomical site: POCUS was superior for glottic evaluation (sensitivity 92.5% vs. 26.4% for XR), whereas XR provided moderate sensitivity (66.7%) at the thoracic inlet, where POCUS was non-diagnostic (sensitivity 0%).

Conclusions: POCUS and XR exhibit high but anatomically dependent complementary accuracy for LTS triage. These findings support an evidence-based, site-directed algorithm using both modalities, with potential to reduce diagnostic delays and improve access to care in resource-limited settings. Trial Registration: Pan African Clinical Trial Registry (PACTR202510808811458) Keywords: Computed Tomography; Diagnostic Accuracy; Global Health; Laryngotracheal Stenosis; Point-of-Care Ultrasound; Radiography; Resource-Limited Settings; Triage.