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Stertor

Stertor is a low-pitched, rumbling, or snoring-like respiratory sound resulting from partial obstruction and turbulent airflow in the upper airway, specifically involving the nasal passages, nasopharynx, or oropharynx, and is typically heard during inspiration. The term stertor originates from the Latin stertere, meaning "to snore".^[1] It differs from stridor, which is a higher-pitched, whistling sound arising from obstructions at or below the larynx, such as in the glottis or subglottis.^[2] Stertor is often associated with conditions causing upper airway narrowing and can occur in both children and adults, serving as a clinical indicator of potential respiratory compromise if severe.^[1] Common causes of stertor include congenital anomalies such as choanal atresia, pyriform aperture stenosis, macroglossia, or glossoptosis, which may present in neonates and infants.^[2] Acquired etiologies encompass adenotonsillar hypertrophy—prevalent in children and linked to obstructive sleep apnea (OSA) with an apnea-hypopnea index greater than 1—along with allergic rhinitis, nasal polyps, foreign bodies, angioedema, infections like Ludwig angina, or trauma including burns.^[2] In veterinary contexts, stertor is similarly noted in animals like cats due to brachycephalic anatomy or nasopharyngeal obstructions.^[3] but human-focused literature emphasizes its role in pediatric OSA, where it may contribute to symptoms like snoring, daytime hyperactivity, and enuresis if untreated.^[2] Severe or persistent stertor can lead to complications such as chronic hypoxia, growth delays in children, or even respiratory failure requiring urgent intervention.^[2] Diagnosis of stertor involves a detailed history and physical examination, including flexible nasopharyngoscopy to visualize obstructions, supplemented by sleep studies to assess for OSA and imaging like CT or MRI for structural anomalies.^[2] Treatment is etiology-specific: conservative measures such as nasal decongestants or allergy management for mild cases; surgical options like adenotonsillectomy for hypertrophic tissues in children, which resolves OSA in most cases; or continuous positive airway pressure (CPAP) for adults with persistent obstruction.^[2] Early evaluation is crucial, as untreated upper airway issues can progress to life-threatening events.^[2]

Definition and Characteristics

Definition

Stertor is defined as a low-pitched, snoring-like respiratory noise produced by turbulent airflow through a partially obstructed upper airway, particularly involving the nasopharynx or oropharynx.^[1]^[4] This sound arises from the vibration of soft tissues in these regions during breathing, typically occurring during inspiration and resembling the noise of snoring.^[5] The term "stertor" originates from the Latin verb stertere, meaning "to snore," which underscores its longstanding association with snoring-like sounds in medical descriptions.^[6]^[7] As a symptom rather than a disease itself, stertor signals partial upper airway obstruction, distinguishing it from more severe or complete blockages that might produce other respiratory noises like stridor or wheezing.^[1]^[5]

Auditory Features and Differentiation

Stertor is characterized by a low-pitched, rumbling or snoring quality, often described as a coarse, non-musical sound resembling nasal congestion or snoring.^[1]^[8] This noise is typically audible during inspiration.^[1]^[4] The sound arises from the vibration of soft tissues in the nasopharynx or oropharynx, triggered by turbulent and irregular airflow resulting from partial obstruction in these regions.^[1]^[8] Unlike smoother airflow in unobstructed breathing, this turbulence causes the pharyngeal structures to flutter, producing the distinctive rumbling tone without the need for auscultation in many cases, as it is often audible from a distance.^[1] Differentiation of stertor from other respiratory sounds is essential for clinical recognition, as it localizes the issue to the upper airway. Stertor, originating from the nasopharynx or oropharynx, presents as low-pitched snoring, in contrast to stridor, which is a high-pitched, harsh or musical wheeze generated by obstruction at the laryngeal or tracheal level and typically more intense during inspiration.^[1]^[8] Wheezing, meanwhile, is a musical, high-pitched sound primarily heard during expiration, arising from narrowing or spasm in the bronchial or smaller lower airways, often requiring a stethoscope for detection.^[9]^[10] These distinctions aid in pinpointing the anatomical site without invasive measures.^[1]

Causes

In Humans

In infants and children, stertor commonly results from congenital anomalies such as bilateral choanal atresia, which causes immediate upper airway obstruction at birth that is often relieved by crying, pyriform aperture stenosis, macroglossia, or glossoptosis.^[2] Enlarged adenoids or tonsils, known as adenotonsillar hypertrophy, represent a very common acquired cause, frequently leading to partial pharyngeal obstruction and associated with obstructive sleep apnea (OSA) in this population.^[2] Nasal congestion due to viral upper respiratory infections or allergies also frequently triggers stertor by narrowing the nasal passages and promoting turbulent airflow.^[4] These etiologies are prevalent in pediatric ear, nose, and throat (ENT) practice, with adenotonsillar hypertrophy contributing to surgical interventions at rates of 19–118 per 10,000 children annually, and noisy breathing like stertor affecting a notable proportion of children experiencing recurrent upper respiratory infections.^[2]^[11] In adults, stertor often stems from obesity-related pharyngeal collapse, where excess adipose tissue in the neck and pharynx narrows the airway during sleep, exacerbating conditions like OSA that impacts approximately 26% of the U.S. adult population.^[2] Other common triggers include nasal polyps, which are noncancerous growths arising from chronic inflammation in the sinuses and nasal lining, leading to persistent obstruction in individuals with allergies, asthma, or frequent infections.^[12] Tumors, such as benign or malignant growths in the nasal cavity or pharynx, can cause stertor by mechanically impeding airflow, though these are less frequent etiologies requiring prompt evaluation.^[13] Post-surgical edema, particularly following procedures like tonsillectomy or sinus surgery, may temporarily produce stertor due to swelling and inflammation in the upper airway tissues.^[2]

In Animals

In veterinary contexts, stertor is a prominent clinical sign in dogs suffering from brachycephalic airway obstruction syndrome (BAOS), a condition prevalent in flat-faced breeds such as English Bulldogs, French Bulldogs, and Pugs. This syndrome stems from conformational abnormalities that narrow the upper airways, including stenotic nares (narrowed nostrils that restrict inspiratory airflow), an elongated and thickened soft palate that obstructs the entrance to the larynx, and everted laryngeal saccules (inverted pouches of tissue in the larynx that further impede breathing). These anomalies generate turbulent airflow, producing the low-pitched, snoring-like stertor during inspiration, which can escalate to respiratory distress under stress.^[14]^[15]^[16] BAOS exhibits high prevalence among predisposed breeds, affecting approximately 50% or more of individuals, with clinical severity often progressing with age due to cumulative tissue inflammation and secondary changes like laryngeal collapse. Exacerbations commonly occur during heat stress, exercise, or obesity, as increased respiratory effort amplifies the obstruction and intensifies the stertorous noise. Early recognition is crucial in these breeds, where even mild cases can evolve into chronic respiratory compromise.^[17]^[18]^[14] In cats, stertor arises from distinct etiologies such as nasopharyngeal polyps—benign growths originating from the Eustachian tube or middle ear that protrude into the nasopharynx and cause partial obstruction—or inhaled foreign bodies that lodge in the nasal cavity or pharynx, leading to turbulent breathing sounds. Inflammatory conditions, including chronic rhinitis or upper respiratory infections, can also contribute by causing mucosal swelling and narrowing of the airways, though these are typically accompanied by sneezing or discharge. Unlike in dogs, feline stertor often presents acutely and requires prompt investigation to rule out obstructive masses.^[19]^[20]^[21] Horses experience stertor less frequently but notably in cases of guttural pouch infections, such as bacterial empyema (purulent accumulation often secondary to strangles caused by Streptococcus equi) or fungal mycosis involving Aspergillus species, which erode pouch walls and lead to severe pharyngeal obstruction. These infections distort the nasopharynx, producing stertor alongside nasal discharge and dysphagia in advanced stages, highlighting the need for endoscopic evaluation in affected equids.^[22]^[23]

Pathophysiology

Mechanism of Airflow Obstruction

Stertor arises from partial narrowing of the nasopharynx or oropharynx, primarily due to tissue redundancy, edema, or structural anomalies that reduce the airway diameter and thereby increase airflow velocity through the constricted passage.^[24] Tissue redundancy, such as enlarged or floppy pharyngeal walls, allows inward collapse under airflow forces, while edema from inflammation or infection further diminishes the lumen size.^[8] Structural anomalies, including congenital malformations like choanal stenosis, contribute similarly by imposing fixed reductions in airway patency.^[25] For instance, in humans, enlarged adenoids represent a common structural cause leading to nasopharyngeal narrowing.^[26] During inspiration, the generation of negative intrathoracic pressure by diaphragmatic contraction is transmitted upstream to the upper airway, exacerbating the collapse of compliant tissues in the already narrowed nasopharynx or oropharynx.^[27] This transmural pressure gradient—where intraluminal pressure becomes more negative relative to surrounding tissues—promotes inward deflection of soft, unsupported pharyngeal walls, further compromising the airway cross-section.^[28] In individuals with inherently lax or redundant tissues, this dynamic collapse intensifies the obstruction, creating a self-reinforcing cycle of narrowing during each inspiratory effort.^[29] From a fluid dynamics perspective, the reduced airway diameter elevates airflow velocity, shifting from laminar to transitional flow when the Reynolds number exceeds approximately 2000, with turbulent flow becoming predominant above 4000, in these narrowed passages, which is the key initiating factor for the disrupted airflow patterns underlying stertor.^[30] The Reynolds number, calculated as Re = (density × velocity × diameter) / viscosity, quantifies this transition; in the upper airway, values above this threshold indicate turbulence due to the high velocities and relatively low viscosity of air.^[31] This turbulent regime arises specifically from the partial obstructions, distinguishing it from smoother laminar flow in unobstructed airways.^[32]

Tissue Vibration and Sound Generation

Stertor arises from the vibration of soft tissues in the upper airway, particularly the pharyngeal walls, soft palate, or uvula, induced by turbulent airflow resulting from partial obstruction. This turbulence generates eddy currents and rapid pressure fluctuations within the narrowed airway, causing these floppy tissues to oscillate as air passes through.^[1]^[33] The acoustic signature of stertor is a low-pitched, rumbling noise, with fundamental frequencies typically ranging from 100 to 500 Hz, reflecting the resonant properties of the vibrating pharyngeal structures. This contrasts with stridor, which produces higher-pitched, more harmonic sounds often exceeding 400 Hz due to vibrations in more rigid laryngeal or tracheal tissues.^[34]^[35] These tissue vibrations contribute to heightened respiratory effort, as the increased airway resistance demands greater inspiratory force, often evident in clinical signs like intercostal retractions or nasal flaring. In severe cases, persistent stertor can lead to hypoxemia by causing hypoventilation, increased work of breathing, and reduced alveolar ventilation.^[1]

Diagnosis

Clinical Assessment

The clinical assessment of stertor commences with a thorough history taking to characterize the onset, progression, and contextual factors of the noisy breathing. An acute onset often points to reversible causes such as infection or foreign body aspiration, whereas a chronic course may suggest congenital anomalies, allergies, or structural issues in both humans and animals.^[2] Associated symptoms are key differentiators: in human infants, feeding difficulties and poor weight gain are frequent, while adults commonly report sleep disruption or daytime fatigue; in veterinary patients, particularly brachycephalic breeds like dogs and cats, exercise intolerance or heat exacerbation is noted.^[14] Exacerbating factors, including positional changes (e.g., worsening when supine) or environmental allergens, should be elicited to guide further evaluation. Physical examination follows, focusing on non-invasive techniques to localize and quantify the obstruction. Inspection reveals signs of distress such as nasal flaring, intercostal or suprasternal retractions, and cyanosis in severe cases, applicable across human pediatric and adult patients as well as veterinary species. Auscultation over the nares, pharynx, and neck helps distinguish nasal from pharyngeal origins of the low-pitched snoring sound characteristic of stertor. In cooperative subjects, flexible nasopharyngoscopy provides preliminary visualization of the nasopharynx and oropharynx to identify obvious obstructions like polyps or edema, often performed without sedation in awake human children or animals.^[36] For chronic cases associated with obstructive sleep apnea (OSA), polysomnography or sleep studies may be indicated to evaluate the severity of airflow obstruction during sleep.^[2] Red flags warranting urgent intervention include progressive worsening of respiratory effort, increasing hypoxia, or altered mental status, signaling potential airway compromise that requires immediate stabilization in humans or animals.^[37]

Imaging and Endoscopic Evaluation

Imaging and endoscopic evaluations play a pivotal role in confirming the anatomical site and character of upper airway obstructions causing stertor, often localizing issues to the nasopharynx or oropharynx. These modalities extend beyond initial clinical suspicion by providing visual confirmation of structural abnormalities, guiding further management without overlapping with basic physical assessments. In humans, lateral neck X-rays serve as an initial, low-radiation imaging tool to detect soft tissue shadows suggestive of obstructions, such as enlarged adenoids or retropharyngeal masses, particularly in pediatric cases with suspected foreign bodies or infections. For more precise delineation in complex scenarios, computed tomography (CT) scans offer detailed three-dimensional reconstructions of airway anatomy, identifying subtle stenoses or polyps that contribute to turbulent airflow. Magnetic resonance imaging (MRI) is favored for soft tissue evaluation, avoiding ionizing radiation and excelling in assessing dynamic pharyngeal structures like lymphoid hypertrophy, though it often requires sedation in young patients.^[2] Endoscopic techniques provide direct, real-time visualization of the upper airway. Flexible fiberoptic laryngoscopy or nasopharyngoscopy allows observation of intraluminal obstructions, including adenoidal tissue or nasal polyps, enabling dynamic assessment of airflow during respiration and biopsy if needed.^[2] In veterinary medicine, particularly for dogs affected by brachycephalic obstructive airway syndrome (BAOS), endoscopic approaches mirror those in humans but emphasize species-specific anatomy. Rhinoscopy and laryngoscopy facilitate direct inspection of stenotic nares, elongated soft palates, and everted laryngeal saccules, confirming obstructive lesions responsible for stertor. CT imaging is routinely employed for objective BAOS grading, quantifying airway dimensions, mucosal contact points, and intranasal turbinate hypertrophy to assess obstruction severity and plan interventions.^[38]

Management

Nonsurgical Approaches

Nonsurgical approaches to managing stertor primarily target reversible causes such as inflammation, infection, allergies, or environmental factors, aiming to alleviate airflow obstruction without invasive procedures. In humans, particularly infants and children where stertor often stems from conditions like nasal congestion or gastroesophageal reflux disease (GERD), treatment focuses on addressing underlying GERD and supportive measures to improve breathing. For instance, pharmacological interventions include proton pump inhibitors (PPIs) or histamine-2 receptor antagonists to manage reflux, which can exacerbate upper airway symptoms; these medications reduce acid production and mitigate irritation in the upper airway.^[39] Nasal steroids and antihistamines are recommended for allergic rhinitis contributing to nasal obstruction, while antibiotics may be prescribed for bacterial rhinosinusitis causing congestion.^[40] Supportive care in humans emphasizes non-pharmacological strategies to ease symptoms. Humidified air via cool-mist humidifiers helps moisten nasal passages and reduce mucosal swelling, particularly in cases of viral upper respiratory infections. Positional therapy, such as elevating the head of the bed while maintaining supine positioning for sleep in infants, can minimize obstruction during sleep or feeding. For obesity-related stertor in adults, weight loss through diet and exercise is advised to decrease soft tissue pressure on the airway. Saline nasal irrigation and suctioning are also employed in pediatric cases to clear nasal secretions. For adults with stertor associated with obstructive sleep apnea (OSA), continuous positive airway pressure (CPAP) or other positive airway pressure therapies are used to maintain airway patency and reduce turbulent airflow.^[41]^[42]^[2] In animals, particularly dogs affected by brachycephalic airway obstruction syndrome (BAOS), nonsurgical management centers on environmental modifications and mild pharmacotherapy for early or mild cases. Weight reduction is a cornerstone, as obesity exacerbates airway collapse; veterinarians often recommend controlled diets to achieve gradual loss, improving respiratory effort and reducing stertor. Anti-inflammatory medications, such as short courses of corticosteroids (e.g., dexamethasone at 0.05–0.1 mg/kg IV), may be used to decrease swelling in acute episodes, though prolonged use is avoided due to risks like gastrointestinal ulceration. Environmental adjustments include avoiding heat and humidity, which worsen panting and obstruction—owners are advised to exercise dogs in cool conditions, use harnesses instead of collars, and maintain a stress-free environment to prevent exacerbation.^[43]^[44]

Surgical Interventions

Surgical interventions for stertor target anatomical obstructions in the upper airway that persist despite conservative measures. In humans, adenotonsillectomy is a primary procedure for children with enlarged tonsils and adenoids contributing to stertor, often associated with sleep-disordered breathing. This surgery involves removal of the palatine tonsils and adenoid tissue to alleviate partial obstruction and reduce noisy breathing.^[45]^[46] For adults experiencing sleep-related stertor linked to oropharyngeal collapse, uvulopalatopharyngoplasty (UPPP) reconstructs the soft palate and uvula by excising excess tissue, thereby widening the airway and diminishing vibration-induced sounds.^[47]^[48] Polypectomy addresses nasal stertor caused by inflammatory polyps obstructing the nasal passages, using endoscopic techniques to resect these growths and restore airflow.^[49]^[50] In veterinary medicine, particularly for dogs with brachycephalic obstructive airway syndrome (BAOS), corrective surgeries focus on breed-specific conformational issues leading to stertor. Alar flare resection widens stenotic nares by removing excess alar fold tissue, improving nasal intake.^[51]^[15] Soft palate shortening, or staphylectomy, trims the elongated soft palate to prevent pharyngeal obstruction and associated snoring-like noises.^[52]^[53] Laryngeal sacculectomy removes everted laryngeal saccules that protrude into the airway, further enhancing ventilation in affected dogs.^[51]^[54] These procedures are indicated when stertor results from fixed anatomical defects, such as congenital anomalies in brachycephalic breeds or persistent lymphoid hypertrophy, and conservative management like weight control or positional therapy fails to provide relief; severe symptoms including exercise intolerance or cyanosis also prompt surgical evaluation.^[55]^[52] Risks associated with these interventions include postoperative bleeding, which occurs in up to 2.6% of adenotonsillectomies, and anesthesia-related complications, heightened in brachycephalic dogs due to preexisting respiratory compromise.^[56]^[15]^[57]

Prognosis

Outcomes in Humans

In children, adenotonsillectomy for stertor associated with obstructive sleep apnea (OSA) achieves resolution rates of 80-90% in non-obese patients without comorbidities, based on significant reduction in apnea-hypopnea index and symptom alleviation.^[58] However, more recent multicenter studies indicate lower complete cure rates (postoperative apnea-hypopnea index <1 event per hour with ≥75% reduction) at approximately 47%, with substantial improvement (apnea-hypopnea index <5 with ≥75% reduction) in about 71% of cases, particularly influenced by factors like obesity and asthma.^[59] In adults, where stertor often manifests as snoring in OSA, surgical interventions such as uvulopalatopharyngoplasty yield variable improvement rates of 50-70%, with success defined as at least a 50% reduction in apnea-hypopnea index and below 20 events per hour.^[60] Potential complications from untreated stertor include recurrent upper respiratory infections, especially if underlying allergic rhinitis contributes to persistent nasal obstruction and eustachian tube dysfunction.^[61] In severe, unmanaged cases, there is a rare but elevated risk of aspiration pneumonia due to increased aspiration propensity from airway collapsibility and impaired airway protection mechanisms.^[62] Long-term outcomes following effective treatment emphasize improved quality of life, with adenotonsillectomy leading to notable enhancements in sleep quality, behavior, and overall well-being, as measured by validated scales like the OSA-18 questionnaire showing mean reductions of over 15 points.^[63] Early intervention also reduces the risk of pulmonary hypertension, a serious sequela of chronic untreated obstruction that can progress to right heart strain in vulnerable pediatric patients.^[64]

Outcomes in Animals

In dogs affected by brachycephalic obstructive airway syndrome (BAOS), surgical interventions demonstrate a success rate of 70-85% in alleviating stertor and reducing respiratory effort, with marked improvements in clinical signs such as noise and exercise tolerance observed in the majority of cases.^[65]^[66] However, residual issues persist in approximately 20% of patients, often necessitating repeat procedures to address persistent obstructions like aberrant turbinate regrowth or incomplete resolution of laryngeal collapse.^[65] Common postoperative complications include aspiration pneumonia, which arises from increased regurgitation and impaired swallowing mechanics, and ongoing heat intolerance due to incomplete restoration of efficient panting and thermoregulation.^[66]^[65] The overall prognosis is more favorable in young animals, particularly those under 2 years of age, where early intervention prevents secondary anatomical changes such as advanced laryngeal collapse, leading to higher rates of significant functional recovery compared to older dogs with chronic adaptations.^[14]^[66] Lifelong management emphasizes regular veterinary monitoring, including annual health assessments and functional grading tests like the 3-minute exercise tolerance evaluation, to detect progression in predisposed breeds such as Bulldogs and Pugs.^[16] These check-ups facilitate timely adjustments to weight management and environmental controls, mitigating exacerbation of stertor in affected animals.^[16]

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Jul 1, 2024 · Brachycephalic obstructive airway syndrome (BOAS) in dogs involves craniofacial abnormalities causing stertor, exercise intolerance, and ...
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Brachycephalic Syndrome - American College of Veterinary Surgeons
Pets must be monitored very closely immediately after surgery. Significant inflammation or bleeding can obstruct the airway, making breathing difficult or ...
[56]
Management & Treatment of BOAS - Cambridge Veterinary School
LATE surgery is indicated for dogs that tend to mouth breathe when at rest, dogs that present with excessive panting during exercise with heat intolerance ...
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Adenotonsillectomy Complications: A Meta-analysis | Pediatrics
Oct 1, 2015 · The most frequent complication was respiratory compromise (9.4%), followed by secondary hemorrhage (2.6%). Four studies compared postoperative ...Missing: polypectomy | Show results with:polypectomy
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[PDF] Brachycephalic Obstructive Airway Syndrome (BOAS)
Indications for Surgery: Pets with BOAS might struggle to breathe, have difficulty sleeping, and will have exercise intolerance – especially in warmer and more ...
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Updates on management of pediatric obstructive sleep apnea - PMC
Adenotonsillectomy has been the treatment of choice in children with OSA with success rates as high as 80%.13 However, residual OSA can occur ...
[60]
Adenotonsillectomy outcomes in treatment of obstructive sleep ...
Sep 1, 2010 · The overall efficacy of adenotonsillectomy (AT) in treatment of obstructive sleep apnea syndrome (OSAS) in children is unknown.
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Should We Stop Performing Uvulopalatopharyngoplasty? - PMC - NIH
UPPP has a reported success rate of approximately 40–60 % for improving mild to moderate OSA [3]. Värendh et al. reported that almost 50 % of patients operated ...
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Allergies in children - PMC - PubMed Central
Many children who suffer from allergic rhinitis present with a chronic congested nose or recurrent upper respiratory infections and are repeatedly treated with ...
[63]
Sleep apnea and risk of pneumonia: a nationwide population-based ...
The higher risk of incident pneumonia among patients with sleep apnea could be attributed to increased aspiration risk and impaired immunity. Following ...Missing: untreated | Show results with:untreated
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Impact of Adenotonsillectomy on Quality of Life in Pediatric ...
Jun 12, 2025 · A significant improvement in quality of life was observed following adenotonsillectomy, with a mean reduction of 15.14 points in OSA-18 scores.
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Association and Risk Factors of Pediatric Pulmonary Hypertension ...
Without effective diagnosis and treatment, children with untreated OSA can develop numerous adverse clinical effects secondary to hypoxic pulmonary ...
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Surgical management of brachycephalic obstructive airway ...
Jul 1, 2024 · Dogs with a BOAS index >50% and a BOAS functional grade of 2–3 at the postoperative follow-up were considered candidates for the LATE procedure.Missing: BAOS | Show results with:BAOS<|control11|><|separator|>
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Brachycephalic obstructive airway syndrome: much more than ... - NIH
Nov 15, 2022 · The prevalence of gastrointestinal disease in brachycephalic dogs presenting for respiratory signs is as high as 97% (Poncet et al. 2005 ...