Diagnostic Accuracy of Point‑of‑Care Ultrasound versus Neck Radiography for Laryngotracheal Stenosis: Complementary Roles in a Resource‑Limited Triage Pathway

Laryngotracheal stenosis (LTS) causes life-threatening airway obstruction, but computed tomography (CT) and endoscopy, the diagnostic reference standards, are often unavailable in low- and middle-income countries. This prospective study compared point-of-care ultrasound (POCUS) and soft tissue neck X-ray (XR) against CT to guide an anatomy-based triage pathway for resource-limited settings. This observational diagnostic accuracy study is registered with the Pan African Clinical Trial Registry (PACTR202510808811458; 06/10/2025). Among 148 patients with suspected LTS, CT confirmed clinically significant stenosis (≥ 50% narrowing) in 99 (66.9%). For overall LTS diagnosis, XR had 93.9% sensitivity and 98.0% specificity. POCUS had 91.9% sensitivity and 93.9% specificity. However, performance varied by airway region. POCUS was more sensitive at the glottis (80.0% versus 26.4% for XR), whereas XR was superior at the thoracic inlet (66.7% versus 0% for POCUS). POCUS was non-diagnostic for the thoracic trachea. Inter-operator reliability was excellent for transverse cervical measurements but lower for glottic and anteroposterior measurements. In a pragmatic analysis counting indeterminate results as test failures, the diagnostic yield of POCUS at the thoracic inlet was 0%. In conclusion, POCUS and neck XR have high overall accuracy for LTS, offering complementary strengths. In settings without CT or endoscopy, an anatomy-guided algorithm using these low-cost tests could reduce diagnostic delays and improve equitable access to care. Prospective validation of this algorithm is required before widespread implementation.