Sleep Health in Toddlers Before and After Adenotomy and Adenotonsillotomy

In Germany, procedures involving the adenoids and tonsils are among the most common surgical interventions in toddlers. Whereas clinical symptoms such as nasal obstruction, mouth breathing, snoring, otitis media with effusion associated with conductive hearing loss, and recurrent infections are readily identified, sleep-related symptoms are often inadequately addressed because of the limited ability to obtain a comprehensive sleep history. Obstructive sleep apnea syndrome (OSAS) in childhood, as characterized by snoring, hypopnoea and apnea, as well as a restless sleep, has a prevalence ranging from 1% to 5%. Adenotonsillar hyperplasia is a major risk factor for OSAS (1). Polysomnography is the diagnostic gold standard but is not readily available in toddlers, therefore the diagnosis is largely based on clinical assessment (2). The aim of the present study was to assess pre- and postoperative sleep health in toddlers with adenotonsillar hyperplasia using questionnaire-based tools and to analyze changes after adenotomy (removal of the adenoids) with or without adenotonsillotomy (additional reduction of the palatine tonsils).

Methods

The prospective study cohort comprised n = 111 toddlers aged between the ages of three and six years (61/111 [55%] male, 50/111 [45%] female), who had undergone either adenotomy (AT; 85/111 [77%]) or adenotonsillotomy (ATT; 26/111 [23%]) between May 2023 and July 2024 at the Department of Otorhinolaryngology of Ulm University Hospital. Median age was five years. The indication for surgery was symptomatic adenotonsillar hyperplasia after guideline-based conservative treatment had been exhausted, in combination with an abnormal OSA-18 or Brouillette score (2). Additional tonsillotomy was performed in children with grade 3 or higher tonsillar hyperplasia associated with symptoms of OSAS. Sleep health was assessed immediately before surgery and three months postoperatively using standardized questionnaires:

• the Children’s Sleep Comic as a child-friendly self-assessment tool evaluating sleep habits, sleep onset difficulties, sleep anxiety, night wakings, dreams, and daytime problems (3) (total score: 0–20 points), and
• the Children’s Sleep Habits Questionnaire (CSHQ-DE), completed by parents and covering bedtime resistance, sleep onset delay, sleep duration, sleep anxiety, night waking, parasomnias, sleep-disordered breathing, and daytime sleepiness (Total Sleep Disturbance Score: 33–99 points) (4).

Higher scores reflected greater impairment of sleep quality. Statistical analyses were descriptive and were performed using the Wilcoxon signed-rank test for pre-/postoperative comparisons and the Mann-Whitney U Test for group comparisons. Correction for multiple testing was not performed. Approval was obtained from the responsible ethics committee.

Results

In the Children’s Sleep Comic, the total cohort demonstrated a mean preoperative score of 6.7 ± 3.3 (95% confidence interval: [6.1; 7.3]; min. 0; max. 16). After surgery this fell to 4.4 ± 2.6 ([3.9–4.9]; min. 0; max. 11; p ≤0.001). Both the AT group (6.48 ± 3.3 [5.7; 7.1]) and the ATT group (7.7 ± 3.2 [6.4; 9.0]) showed improvements (AT: 4.4 ± 2.8 ([3.8; 5.0]; p ≤0.001) versus ATT: 4.6 ± 1.9 ([3.8; 5.8]; p ≤0.001), with no relevant differences in treatment outcomes between the surgical procedures (p = 0.515).

Before surgery, the CSHQ-DE had an elevated Total Sleep Disturbance Score of 53.7 ± 8.6 ([52.1; 55.4]; min. 37; max. 76). Postoperatively, however, this fell to 44.4 ± 6.2 ([43.2; 45.6]; min. 33; max. 67; p ≤0.001). Improvements were confirmed both after AT (53.3 ± 8.2 versus 44.8 ± 6.6 points) and after ATT (54.9 ± 9.7 versus 43.4 ± 4.9 points), with no difference in the magnitude of the reduction. The subscale analysis showed improvements in the overall cohort in all eight domains (p ≤0.001).

The scores of both questionnaires are presented in the Figure. Detailed subscale and total scores of the Children’s Sleep Comic are presented in the Table.

Figure

Pre- and postoperative comparison of the total scores of the CSHQ-DE and the Children’s Sleep Comic

Table

Pre- and postoperative descriptive analysis of the CSHQ-DE subscales and the Children’s Sleep Comic

Discussion

Using two complementary assessment tools, this study showed for the first time that toddlers with symptomatic adenotonsillar hyperplasia experience a clinically relevant multidimensional impairment in sleep health. The combination of self-assessment and parent-reported assessment recorded subjective and observable sleep problems in a more detailed manner. Both tools were in agreement in demonstrating a postoperative improvement in sleep health. At the same time, children with adenotonsillar hyperplasia consistently demonstrated more pronounced preoperative sleep disturbances than children with adenoid hyperplasia alone, particularly in the domains of sleep-disordered breathing and sleep duration, reflecting a higher degree of airway obstruction. In the overall cohort, the greatest postoperative improvements were in the domains sleep-disordered breathing, parasomnias, and daytime sleepiness. In contrast, behavior-related domains, such as sleep anxiety and bedtime resistance, continued to show elevated scores. The postoperative CSHQ-DE total score (44.4) remained above the cut-off value of 41, indicating residual sleep problems after surgery. Postoperative improvement was more pronounced in the present study than in comparable studies which predominantly evaluated adenotonsillectomy (5). This is due to the OSAS-oriented indications for surgery, the exclusion of children with recurrent tonsillitis, and the younger patient cohort. Given the pre-/postoperative observational design without a control group, however, it remains uncertain to what extent a regression to the mean is responsible for the observed changes.

Conclusion

Sleep-related symptoms represent a hitherto underestimated indication for surgery in toddlers with adenotonsillar hyperplasia. Surgical treatment can markedly improve sleep health in patients with clinically relevant OSAS symptoms. The differential diagnosis of adenotonsillar hyperplasia should be considered early in toddlers with signs of disturbed sleep, without necessarily deriving an indication for surgery from this.

Conflict of interest statement
The authors declare that no conflict of interest exists.
Manuscript received on 12 January 2026, revised version accepted on 2 April 2026.
Translated from the original German by Dr. Grahame Larkin.

Cite this as: Lindemann J, Hoffmann TK, Hahn J, Gschwend G, Leitgeb R, Gojnic M: Sleep health in toddlers before and after adenotomy and adenotonsillotomy. Dtsch Arztebl Int 2026; 123: 362–3.
DOI: 10.3238/arztebl.m2026.0058

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