Parents usually arrive at this question in one of two moments.
In the first, an ENT has just recommended taking out their child's tonsils and adenoids, and they are hoping there is a way around an operation. In the second, the surgery already happened, a year has gone by, and the snoring, the open mouth, or the restless sleep is back.
Both are reasonable questions. Neither of them is really a versus.
The Short Answer
A tonsillectomy removes tissue. If enlarged tonsils and adenoids are physically narrowing the airway, surgery is the only thing on this page that can change that, and no amount of exercise substitutes for it.
Orofacial myofunctional therapy retrains muscles and habits: where the tongue rests, whether the lips seal, how the swallow works, whether breathing goes through the nose. It cannot shrink tonsils.
Which means they do different jobs. The honest framing is not therapy instead of surgery, but understanding what surgery does, what it reliably leaves behind, and where retraining fits in the sequence.
What a Tonsillectomy Actually Does
Tonsillectomy is among the most common operations performed on American children. The 2019 clinical practice guideline from the American Academy of Otolaryngology-Head and Neck Surgery Foundation puts the figure at "289,000 ambulatory procedures performed annually in children" under 15 years of age.
Children are referred for two broad reasons. One is recurrent throat infection, where the guideline is notably conservative: clinicians "should recommend watchful waiting" unless the episode count crosses a specific threshold across one, two, or three years. The other, and the one that brings families to a myofunctional therapist, is obstructive sleep-disordered breathing — snoring, pauses, mouth breathing, restless sleep, and the daytime fallout that comes with it.
For that group the guideline is direct: clinicians "should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography." It also lists the children who should have a sleep study before surgery rather than after, including those under 2 and those with obesity, Down syndrome, craniofacial differences, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. And it asks clinicians to talk with families about the things that may improve afterward, naming "growth retardation, poor school performance, enuresis, asthma, and behavioral problems."
Surgery works. The Childhood Adenotonsillectomy Trial (Marcus et al., New England Journal of Medicine, 2013) randomly assigned 464 children aged 5 to 9 with obstructive sleep apnea to early adenotonsillectomy or watchful waiting with supportive care. At 7 months, sleep-study findings normalized in 79% of the surgical group compared with 46% of those who waited, and the surgical group had significantly better behavior, quality of life, and symptom scores.
It is worth noting what that trial did not find, because it is a useful check on expectations. Its primary outcome, a measure of attention and executive function, did not differ significantly between the two groups.
What a Tonsillectomy Does Not Do
This is where the conversation with families usually gets more useful, and it is not a myofunctional therapist's opinion. It is in the surgical guideline itself, which tells clinicians they "should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management."
The numbers behind that sentence are worth seeing. A multicenter study of 578 otherwise healthy children who had sleep studies both before and after adenotonsillectomy (Bhattacharjee et al., American Journal of Respiratory and Critical Care Medicine, 2010) found a large average improvement: the apnea-hypopnea index fell from 18.2 to 4.1 events per hour of sleep. But only 157 of those 578 children, 27.2%, had complete resolution. The authors concluded that "residual disease is present in a large proportion of children after AT, particularly among older (over 7 yr) or obese children."
Then there is the habit side. Surgery can open a nasal airway; it does not automatically retrain a child who has spent years breathing through an open mouth with the tongue resting low. A study that followed 40 children for 24 months after adenoidectomy or adenotonsillectomy (Valera et al., International Journal of Pediatric Otorhinolaryngology, 2006) scored facial posture, muscle tone, chewing, swallowing, and breathing before and after surgery. Scores improved, but "partial[ly]" — and the improvement happened almost entirely in the first 6 months, after which it stopped being statistically significant. Children who still had allergic rhinitis improved least, which the authors describe plainly: a "persistent pattern of mouth breathing due to allergic rhinitis may difficult recovery of the myofunctional status."
Their closing point is the one we see play out in practice. The timing of the referral from surgeon to therapist, they write, "seems to be crucial," as does the therapist recognizing when obstructive symptoms are still present and sending the child back to the physician.
Where Myofunctional Therapy Fits
ASHA's clinical guidance on orofacial myofunctional disorders states the goal of therapy this way: "The primary purpose of orofacial myofunctional therapy (OMT) is to create an oral environment in which typical processes of orofacial and dental growth and development can take place and be maintained."
It also names tonsils directly, in the section on why nasal breathing fails: "Enlarged tonsils, adenoids, hypertrophied turbinates, and/or allergies do not allow for effortless inspiration and expiration." And it sets the order of operations in a way that should settle the versus question on its own. "Closed-mouth posture cannot be consistently established until any airway interferences have been successfully resolved," and lip closure work is addressed only "after structural or physiological impediments to nasal breathing — including allergies — have been ruled out or corrected via evaluations by an allergist and otolaryngologist/ENT."
Read that as written: the profession's own guidance puts the ENT first. Therapy is what happens once the air can actually get through.
For the airway specifically, the evidence for therapy is real but modest. A systematic review and meta-analysis in Sleep (Camacho et al., 2015) concluded that myofunctional therapy "decreases apnea-hypopnea index by approximately 50% in adults and 62% in children," and that it "could serve as an adjunct to other obstructive sleep apnea treatments." Adjunct is the operative word, and ASHA adds its own caveat that "more studies are needed to evaluate compliance and the long-term effects of OMT on obstructive sleep apnea outcomes."
The recurrence question
The most interesting study for families who have already had surgery is Guilleminault et al., Sleep Medicine, 2013. The researchers followed 24 children whose sleep studies were normal after adenotonsillectomy and orthodontic treatment, and who were all referred for myofunctional therapy. Eleven completed it. Thirteen did not. At follow-up between 22 and 50 months later, all 11 who completed therapy "revealed healthy results," while the 13 who did not had symptoms return with a mean apnea-hypopnea index of 5.3. The authors' conclusion: "Absence of myofascial treatment is associated with a recurrence of SDB."
That is a striking result, and it deserves an honest asterisk. It is small, retrospective, and not randomized — the children were not assigned to therapy, they either did it or did not, which leaves room for other differences between the groups. The authors themselves note that complete long-term charts were limited. It is also the pediatric study that supplied the 62% figure in the Camacho meta-analysis above, so the two are not independent confirmations of each other. Treat it as a strong signal worth acting on, not as settled science.
How the Two Actually Sequence
- Before surgery. If an ENT has recommended a tonsillectomy for documented obstructive sleep apnea, that decision belongs to the ENT. Therapy does not shrink tonsils and should not be used to delay an operation your child needs. What an evaluation can do beforehand is document where the tongue rests, whether there is a tongue thrust or a restricted tongue, and what the swallow looks like — a useful baseline for afterward.
- If the ENT recommends waiting. Plenty of children snore, mouth-breathe, or sleep restlessly without meeting the criteria for surgery. That is the situation where the muscle-and-habit side of the picture is often the whole picture, and where a myofunctional evaluation earns its place.
- After surgery. This is the most common referral we see, and the Valera findings suggest why the timing matters: the spontaneous improvement mostly happens in the first 6 months and then levels off. Ask your surgeon when the airway is considered open and healing is complete, and start from there.
- When symptoms come back. Mouth breathing that returns after surgery is worth taking seriously rather than shrugging off. Our guide to mouth breathing in children covers the full list of causes, and chronic mouth breathing explains the therapy side. If the snoring is back, that is a call to the physician first, not to us.
When Neither One Is the Answer
Sometimes the obstruction is not the tonsils and not the muscles. Allergies, a deviated septum, and hypertrophied turbinates all keep a mouth open, and the Valera study is a reminder that untreated allergic rhinitis can hold a child in a mouth-breathing pattern even after successful surgery. Weight is a factor too — the Bhattacharjee data flagged body mass index as one of the two strongest predictors of residual apnea after surgery.
None of that is diagnosable by a myofunctional therapist. ASHA is explicit that "SLPs do not differentially diagnose medical conditions," and that they refer to physicians when concerns about sleep-disordered breathing come up during an evaluation. That is exactly how we operate.
What to Ask Your Child's ENT
If you are heading into a tonsillectomy consultation, these are the questions that make the myofunctional side easier to plan:
- Is a sleep study part of the plan, before surgery or after?
- Given my child's age and history, how likely is some sleep-disordered breathing to persist after surgery?
- Are allergies or nasal congestion contributing, and should we be treating those too?
- When would you consider the airway open enough to work on breathing and swallowing habits?
- Is there a reason to expect the tongue's resting posture to change on its own?
Where We Come In
Laura Friedman holds both the CCC-SLP and the QOM (Qualified Orofacial Myologist) credentials, and works alongside ENTs, sleep physicians, dentists, and orthodontists rather than in place of them. We do not perform surgery, order sleep studies, or diagnose sleep apnea.
What we do is the retraining part: nasal breathing, lip seal, tongue resting posture, and the swallow, through short daily practice over several months. If that is the piece your child is missing after a tonsillectomy, schedule a free consultation — in person in Dallas or through online myofunctional therapy nationwide. Our page on myofunctional therapy for sleep apnea and airway health explains how that works alongside a sleep team, and our guide to myofunctional therapy exercises shows what the daily work looks like.
And if the answer after an evaluation is that your child needs to see the ENT again first, you will hear that instead.
Frequently Asked Questions
Can myofunctional therapy help my child avoid a tonsillectomy?
Not if enlarged tonsils and adenoids are physically blocking the airway. Exercises do not shrink tonsil tissue, and whether surgery is needed is an ENT's call, usually with a sleep study behind it. ASHA's guidance is that a closed-mouth resting posture cannot be established until airway interferences have been resolved. Where therapy matters is on the muscle-and-habit side, and in cases where the ENT has already recommended watchful waiting.
Does a tonsillectomy fix mouth breathing and snoring for good?
Often it helps a great deal, but not always completely. The AAO-HNS guideline tells clinicians to counsel families that obstructive sleep-disordered breathing "may persist or recur after tonsillectomy and may require further management." In 578 children studied before and after surgery, the average apnea-hypopnea index fell from 18.2 to 4.1 events per hour, but only 27.2% had complete resolution, with older and heavier children most likely to have residual disease.
Should myofunctional therapy happen before or after tonsil surgery?
Usually after, because nasal breathing has to be possible before you can train it. In 40 children followed after adenoidectomy or adenotonsillectomy, myofunctional status improved mainly in the first 6 months and then plateaued, and the researchers called the timing of the referral from surgeon to therapist crucial. Ask your ENT when the airway is considered open, and start from there.
Is there evidence that myofunctional therapy prevents sleep apnea from coming back after surgery?
There is suggestive evidence, not proof. In a 2013 study of 24 children whose sleep studies were normal after adenotonsillectomy and orthodontic treatment, the 11 who completed myofunctional therapy stayed healthy at follow-up while the 13 who did not had symptoms return. It is small, retrospective, and not randomized, so read it as a signal rather than a settled answer.
Does Bloom perform or recommend tonsil surgery?
No. Laura Friedman is a speech-language pathologist and Qualified Orofacial Myologist, not a physician. We do not diagnose sleep apnea, order sleep studies, or decide whether tonsils should come out. If an evaluation here turns up signs of obstructed nasal breathing, the referral goes back to your pediatrician, ENT, or sleep physician.
Not Sure Which Piece You Are Missing?
If your child has had a tonsillectomy and the open mouth or the snoring has come back, or if you are trying to understand where therapy fits around a surgery that has been recommended, schedule a free consultation with Laura Friedman, CCC-SLP and Qualified Orofacial Myologist. You will get an honest read on what retraining can and cannot change — and if the next call should be to your ENT, you will hear that first.