Skip to main content
Log in

Mouth breathing, “nasal disuse,” and pediatric sleep-disordered breathing

  • Original Article
  • Published:
Sleep and Breathing Aims and scope Submit manuscript



Adenotonsillectomy (T&A) may not completely eliminate sleep-disordered breathing (SDB), and residual SDB can result in progressive worsening of abnormal breathing during sleep. Persistence of mouth breathing post-T&As plays a role in progressive worsening through an increase of upper airway resistance during sleep with secondary impact on orofacial growth.


Retrospective study on non-overweight and non-syndromic prepubertal children with SDB treated by T&A with pre- and post-surgery clinical and polysomnographic (PSG) evaluations including systematic monitoring of mouth breathing (initial cohort). All children with mouth breathing were then referred for myofunctional treatment (MFT), with clinical follow-up 6 months later and PSG 1 year post-surgery. Only a limited subgroup followed the recommendations to undergo MFT with subsequent PSG (follow-up subgroup).


Sixty-four prepubertal children meeting inclusion criteria for the initial cohort were investigated. There was significant symptomatic improvement in all children post-T&A, but 26 children had residual SDB with an AHI > 1.5 events/hour and 35 children (including the previous 26) had evidence of “mouth breathing” during sleep as defined [minimum of 44 % and a maximum of 100 % of total sleep time, mean 69 ± 11 % “mouth breather” subgroup and mean 4 ± 3.9 %, range 0 and 10.3 % “non-mouth breathers”]. Eighteen children (follow-up cohort), all in the “mouth breathing” group, were investigated at 1 year follow-up with only nine having undergone 6 months of MFT. The non- MFT subjects were significantly worse than the MFT-treated cohort. MFT led to normalization of clinical and PSG findings.


Assessment of mouth breathing during sleep should be systematically performed post-T&A and the persistence of mouth breathing should be treated with MFT.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2

Similar content being viewed by others


  1. Guilleminault C, Partinen M, Praud JP, Quera-Salva MA, Powell N, Riley R (1989) Morphometric facial changes and obstructive sleep apnea in adolescent. J Pediatr 114:997–999

    Article  CAS  PubMed  Google Scholar 

  2. Tasker C, Crosby JH, Stradling JR (2002) Evidence for persistence of upper airway narrowing during sleep, 12 years after adenotonsillectomy. Arch Dis Child 86:34–37

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  3. Tauman R, Gulliver TE, Krishna J, Montgomery-Down HE, O’Brien L, Ivannenko A, Gozal D (2006) Persistence of obstructive sleep apnea syndrome in children after adenotonsillectomy. J Pediatr 149:803–808

    Article  PubMed  Google Scholar 

  4. Guilleminault C, Huang YS, Glamann C, Li KK, Chan A (2007) Adenotonsillectomy and obstructive sleep apnea in children: a prospective survey. Otolaryngol Head Neck Surg 136:169–175

    Article  PubMed  Google Scholar 

  5. Amin R, Anthony L, Somers V et al (2008) Growth velocity predicts recurrence of sleep-disordered breathing 1 year after adenotonsillectomy. Am J Respir Crit Care Med 177:654–659

    Article  PubMed Central  PubMed  Google Scholar 

  6. Bhattacharjee R, Kheirandish-Gozal L, Spruyt K, Mitchell RB, Promchiarak J, Simakajornboon N, Kaditis AG, Splaingard D, Splaingard M, Brooks LJ, Marcus CL, Sin S, Arens R, Verhulst SL, Gozal D (2010) Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children: a multicenter retrospective study. Am J Respir Crit Care Med 182:676–683

    Article  PubMed  Google Scholar 

  7. Huang YS, Guilleminault C, Lee LA, Lin CH, Hwang FM (2014) Treatment outcomes of adenotonsillectomy for children with obstructive sleep apnea: a prospective longitudinal study. Sleep 37:71–76

    PubMed Central  PubMed  Google Scholar 

  8. Vlahandonis A, Nixon GM, Davey MJ, Walter LM, Horne RS (2013) A four year follow-up of sleep and respiratory measures in elementary school-aged children with sleep disordered breathing. Sleep Med 14:440–448

    Article  PubMed  Google Scholar 

  9. Harvold E, Tomer B, Vargervik K, Chierici G (1981) Primate experiments on oral respiration. Am J Orthod 79:359–372

    Article  CAS  PubMed  Google Scholar 

  10. Vargervik K, Miller AJ, Chierici G, Harvold E, Tomer BS (1984) Morphologic response to changes in neuromuscular patterns experimentally induced by altered modes of respiration. Am J Orthod 85:115–124

    Article  CAS  PubMed  Google Scholar 

  11. Linder-Aronson S (1969) Dimensions of face and palate in nose breathers and habitual mouth breathers. Odontol Revy 14:187–200

    Google Scholar 

  12. Linder-Aronson S (1970) Adenoids. Their effect on mode of breathing and nasal airflow and their relationship to characteristics of the facial skeleton and the denition. A biometric, rhino-manometric and cephalometro-radiographic study on children with and without adenoids. Acta Otolaryngol Suppl 265:1–132

    CAS  PubMed  Google Scholar 

  13. Mcnamara JA (1981) Influence of respiratory pattern on craniofacial growth. Angle Orthod 51:269–300

    CAS  PubMed  Google Scholar 

  14. Lime M (1993) Orthognathic and orthodontic consequences of mouth breathing. Acta Otorhinolaryngol Belg 47:145–155

    Google Scholar 

  15. Ricketss RM (1958) Respiratory obstructions and their relation to tongue posture. Cleft Palate Bull 8:3–6

    Google Scholar 

  16. Huang YS, Guilleminault C (2013) Pediatric obstructive sleep apnea and the critical role of orofacial growth: evidences. Front Neurol 3:1–7

    Article  Google Scholar 

  17. Fitzpatrick M, Driver H, Chata N, Vodue N, Girard A (2003) Partitioning of inhale ventilation during sleep in normal subjects. J Appl Physiol 91:883–890

    Article  Google Scholar 

  18. Fitzpatrick M, McLean H, Urton AM, Tan A, O’Donell ED (2003) Effect of oral or nasal breathing route on upper airway resistance during sleep. Eur Respir J 22:827–832

    Article  CAS  PubMed  Google Scholar 

  19. Guilleminault C, Huang YS, Monteyrol PJ, Sato R, Quo S, Lin CH (2013) Critical role of myofunctional reeducation in sleep-disordered-breathing. Sleep Med 14:518–525

    Article  CAS  PubMed  Google Scholar 

  20. Chauvois A, Fournier M, Girardin F (1991) Reeducation des fonctions dans la therapeutique orthodontiques. Paris, S.I.D

  21. Smithpeter J, Covell D (2010) Relapse of anterior open bites treated with orthodontic appliances with and without orofacial myofunctional therapy. Am J Orthod Dentofacial Orthop May 137:605–614

    Article  Google Scholar 

  22. Hunt N, Shah R, Sinanan A, Lewis M (2007) [Muscular interference in malocclusion: present concepts of the role of the muscles in the etiology and therapy of malocclusion]. Orthod Fr (French) 78:79–88

    Article  Google Scholar 

  23. Josell SD (1995) Habits affecting dental and maxillofacial growth and development. Dent Clin N Am 39:851–860

    CAS  PubMed  Google Scholar 

  24. Denotti G, Ventura S, Arena O, Fortini A (2014) Oral breathing: new early treatment protocol. JP J Pediatr Neonatal Individualized Med 3:e030108

    Google Scholar 

  25. Villa MP, Brasili L, Ferretti A, Vitelli O, Rabasco J, Mazzotta AR, Pietropaoli N, Martella S (2014) Oropharyngeal exercises to reduce symptoms of OSA after AT. Sleep Breath. doi:10.1007/-s11325-014-1011

  26. Guilleminault C, Sullivan SS (2014) Toward restauration of continuous nasal breathing as the ultimate treatment goal in pediatric obstructive sleep apnea. Pediatr Neonatol Biol 1:1–7

    Google Scholar 

  27. Camacho M, Certal V, Abdullatif J, Zaghi S, Ruoff CM, Capasso R, Kushida C (2014) Myofunctional therapy to treat obstructive sleep apnea: a systematic review and meta-analysis. Sleep (in press)

  28. Puhan MA, Suarez A, Cascio CL, Zahn A, Heitz M, Braendli O (2005) Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome: randomised controlled trial. BMJ 332:266–270

    Article  PubMed  Google Scholar 

  29. Guimarães KC, Drager LF, Genta PR, Marcondes BF, Lorenzi-Filho G (2009) Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome. Am J Respir Crit Care Med 179(10):962–966

    Article  PubMed  Google Scholar 

  30. Chervin RD, Hedger K, Dillon JE, Pituch KJ (2000) Pediatric sleep questionnaire (PSQ): validity and reliability of scales for sleep disordered breathing, snoring, sleepiness, and behavioural problems. Sleep Med 1:21–32

    Article  PubMed  Google Scholar 

  31. Kim JH, Guilleminault C (2011) The naso-maxillary complex, the mandible and sleep disordered breathing. Sleep Breath 15:185–193

    Article  PubMed  Google Scholar 

  32. Carrillo O, Sullivvan SS, Blake J (2010) A novel method for detecting oral breathing during PSG. Sleep 33 supplA139 (abstract)

  33. Iber C, Ancoli-Israel S, Chesson AL, Jr., Quan SF. for the American Academy of Sleep Medicine (addended Berry RB, Brooks R, Gamaldo CE). (2012) The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications. Version 2.0., Darian Ill: American Academy of Sleep Medicine

  34. Palombini L, Tufik S, Rapoport D, Ayappa I, Guilleminault C, de Godoy L, Casto L, Bittencourt L (2013) Inspiratory flow limitation in a normal population of adults in Sao Paolo, Brazil. Sleep 36:1663–1668

    PubMed Central  PubMed  Google Scholar 

  35. Guilleminault C, Li KK, Khramtsov A, Pelayo R, Martinez S (2004) Sleep-disordered breathing: surgical outcome in prepubertal children. Laryngoscope 114:132–137

    Article  PubMed  Google Scholar 

  36. Souki BQ, Lopes PB, Pereira TBJ, Franco LP, Becker HMG, Oliveira DD (2012) Mouth breathing children and cephalometric pattern: does the dental age matter? Int J Pediatr OtorhinoLaryngol 76:837–841

    Article  PubMed  Google Scholar 

Download references


Dr. Seo-Young Lee was a visiting associate professor at the Stanford University Sleep Medicine Division and was financially supported by the Kangwon National University College of Medicine during her sabbatical year. We greatly appreciated advices, comments, and corrections from Dr. Stacey Quo DDS, University of California San Francisco Dental School.

Ethical considerations

This retrospective study on data rendered anonymous was approved by the IRB.

Conflict of interest

None of the authors has conflict of interest.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Christian Guilleminault.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lee, SY., Guilleminault, C., Chiu, HY. et al. Mouth breathing, “nasal disuse,” and pediatric sleep-disordered breathing. Sleep Breath 19, 1257–1264 (2015).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: