Adolescent and adult laryngotracheal stenosis (AALTS) is a debilitating condition whose diagnosis is frequently delayed, often for years, due to symptomatic mimicry of common respiratory diseases. This diagnostic journey is compounded by the critical distinction between immature (fibroinflammatory) and mature (cicatricial) disease phases, which dictate divergent management pathways. The primary aim of this review is to systematically map the evidence on diagnostic approaches for AALTS, critically evaluate their application across diverse healthcare resource settings, and propose a novel, context-specific diagnostic algorithm to bridge the global disparity in diagnostic delays. This review identifies a predominant (≈ 80%) iatrogenic aetiology for AALTS. Laryngotracheobronchoscopy (LTB) remains the diagnostic cornerstone, enabling definitive anatomical classification and concurrent therapeutic intervention; however, its invasiveness and resource intensity restrict its global utility. Cross-sectional imaging, notably computed tomography with virtual bronchoscopy, provides excellent anatomical detail for preoperative planning but lacks dynamic functional assessment and exposes patients to radiation. Spirometry offers a non-invasive functional correlate, with characteristic flow-volume loops indicating fixed obstruction, yet it is incapable of defining stenosis morphology. The synthesis of evidence reveals profound global disparities: resource-limited settings often rely on radiography for initial screening, contributing to an average diagnostic delay of 22 months and worse patient outcomes compared to resource-rich environments. Emerging evidence also supports bedside ultrasonography as a low-cost screening and triage tool for suspected AALTS, particularly in resource-limited settings. We establish that timely and accurate diagnosis is paramount for phase-appropriate intervention in AALTS. To address the documented disparities, this review introduces a tiered-diagnostic algorithm that strategically employs available tools - from spirometry and ultrasonography in low-resource settings to advanced imaging in well-resourced centres - to establish a probable diagnosis and prioritize referral for definitive LTB. The validation and implementation of such context-specific pathways are essential to mitigate diagnostic delays, guide less invasive treatments, and achieve equitable care worldwide.
Klopper et al. (Tue,) studied this question.