Abstract
<title>Abstract</title> <p>Laryngotracheal stenosis (LTS) management is complex, but evidence on how social determinants and health-system constraints affect outcomes in low-resource settings is limited. This 20-year retrospective cohort study of 126 consecutive patients treated at a South African tertiary referral centre quantified socioeconomic status (SES), diagnostic interval, and treatment delay, and examined associations with disease severity, intervention complexity, and decannulation success using Elastic Net regularised logistic regression and Random Forest. Among patients (median age 30 years [IQR 23–42]; 63.5% male), 73.0% had high-grade stenosis, 84.9% required open surgery, and 54.8% achieved decannulation. Median diagnostic interval was 4 months (IQR 2–6) and treatment delay 2 months (IQR 0–5), with no SES differences (p > 0.05). Neither delay predicted outcomes after adjustment for aetiology and comorbidity. Traumatic aetiology was the strongest positive predictor of decannulation success (β=+0.317), while laryngopharyngeal reflux (β=-0.329) and acute life-threatening presentation (β=-0.118) were the strongest negative predictors. The prognostic model achieved excellent discrimination (AUC 0.84; 95% CI 0.77–0.91) and good calibration (intercept 0.02; slope 0.96). Diagnostic and treatment delays were universal, not patterned by SES, and added no independent prognostic value once aetiology and comorbidity were accounted for. SES influenced outcomes indirectly through aetiology, consistent with social embodiment. Interventions to improve decannulation success should prioritise aetiology-specific prevention, systematic comorbidity management, and surgical capacity building. This “equality of poor outcomes” phenomenon suggests that universal system-level constraints may attenuate observable socioeconomic gradients in clinical outcomes.</p>