Impact of Adenoidectomy on Emotional, Social, and Academic Development in Children: A Longitudinal Cohort Study

Abstract

Adenoid hypertrophy (AH) is a common condition in children, leading to obstructive sleep apnea (OSA), recurrent infections, and nasal breathing issues, which impact emotional and social growth. Although adenoidectomy is a common treatment, its broader effects on emotional, social, and academic development are underexplored. This longitudinal observational cohort study, conducted from January 2020 to December 2021 at a tertiary care center, involved 200 children aged 4 to 10 years with AH. Assessments were performed pre-surgery and at 6-, 12-, 18-, and 24-months post-surgery. Data collection included the Strengths and Difficulties Questionnaire (SDQ), Child Behaviour Checklist (CBCL), Paediatric Quality of Life Inventory (PedsQL), polysomnography, school reports, standardized test scores, and social interaction analysis. Statistical analyses utilized SPSS version 27, employing repeated measures ANOVA, Pearson correlation coefficients, and multivariate regression analysis. Post-surgery, significant improvements were observed. Emotional symptoms decreased by 33%, conduct problems by 29%, and hyperactivity by 27% (p < 0.001). Social functioning scores improved by 27%, with enhancements in peer relationships and group activity participation (p < 0.001). Academic performance increased by 24%, particularly in sustained attention and cognitive flexibility (p < 0.001). The Apnea-Hypopnea Index (AHI) decreased by 84%, correlating strongly with behavioural and emotional improvements (p < 0.001). Emotional regulation and social interactions were the most significantly impacted, while basic arithmetic skills were the least affected. Adenoidectomy significantly benefits the emotional, social, and academic development of children with AH. Early intervention and a multidisciplinary approach involving ENT specialists, paediatricians, psychologists, and educators are essential for mitigating the impacts of AH. Future research should explore long-term outcomes and the mechanisms linking improved sleep quality with developmental progress.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-024-05111-x.

Introduction

Adenoid hypertrophy (AH) is a common condition in paediatric populations, characterized by the abnormal enlargement of the adenoid tissue. This condition often results in significant morbidity due to its impact on the upper airway, leading to obstructive sleep apnea (OSA), recurrent infections, and impaired nasal breathing. The prevalence of AH is high among children, with substantial implications for their overall health and development (Pereira L et al., 2018) [1]. Despite its prevalence, the impact of AH on various aspects of childhood development, particularly emotional and social growth, remains underexplored.

The relationship between AH and sleep-disordered breathing has been well-documented, with numerous studies highlighting the negative consequences on cognitive and behavioural outcomes (Kaditis et al., 2016) [2]. Children with AH and resultant OSA often exhibit symptoms such as daytime sleepiness, attention deficits, and hyperactivity, which can adversely affect their academic performance and social interactions (Witmans M et al., 2011) [3]. However, while the physical and cognitive impacts of AH have been studied extensively, there is a paucity of research focusing specifically on the emotional and social domains of affected children’s lives.

Surgical intervention, particularly adenoidectomy, is a common treatment for AH, aimed at alleviating airway obstruction and improving sleep quality. Previous studies have shown that adenoidectomy can lead to improvements in cognitive and behavioural symptoms associated with AH (Domany KA et al., 2016) [4]. However, the effects of this surgical intervention on emotional regulation and social interactions are less well understood. This study aims to fill this gap by evaluating the emotional, social, and academic outcomes in children with AH, both pre- and post-adenoidectomy, over a two-year period. By employing a longitudinal observational cohort design, this study seeks to provide a comprehensive understanding of the developmental impacts of AH and the benefits of timely surgical intervention.

Methodology

Study Design and Setting

This longitudinal observational cohort study was conducted over a two-year period from January 2020 to December 2021 at the ENT department of a tertiary care center with a defence setup. Children diagnosed with adenoid hypertrophy were assessed before surgery and at multiple intervals post-surgery (6, 12, 18, and 24 months).

Participants

Initially, 250 children aged 4 to 10 years diagnosed with adenoid hypertrophy were eligible for the study. After applying the inclusion and exclusion criteria, 200 children were recruited consecutively from the ENT department.

• Inclusion criteria were children diagnosed with adenoid hypertrophy who were scheduled for adenoidectomy.

• Exclusion criteria Children with congenital anomalies, neurological disorders, or chronic illnesses that could affect their emotional or social development were excluded from the study. Additionally, 50 participants were excluded due to these criteria or their inability to provide consent.

Data Collection

Assessments were carried out at baseline (before surgery) and at 6-, 12-, 18-, and 24-months post-surgery.

Subjective Metrics

1. Parent-Reported Questionnaires: Parents completed the Strengths and Difficulties Questionnaire (SDQ) (Supplement Sheet: S1) and the Child Behaviour Checklist (CBCL) ((Supplement Sheet: S2) to assess emotional and behavioural issues.

2. Child Self-Reports: Age-appropriate self-report tools, the Paediatric Quality of Life Inventory (PedsQL), were used to gather children’s perspectives on their emotional and social experiences (Supplement Sheet: S3).

Objective Metrics

1. Sleep Studies: Polysomnography was conducted to assess the severity of sleep apnea and its correlation with behavioural issues. The Apnea-Hypopnea Index (AHI) was used to quantify the severity of sleep-disordered breathing (Supplement Sheet: S4: ApneaLink Air Level 3 device).

2. Academic Performance: School reports and standardized test scores were collected to evaluate the impact on cognitive and academic performance (Supplement Sheet: S5).

3. Social Interaction Analysis: Observations of social interactions in school and home environments were recorded and analysed using a standardized observational checklist (Supplement Sheet: S6).

Variables

• Exposure Variable: The primary exposure variable was the diagnosis of adenoid hypertrophy and subsequent surgical intervention (adenoidectomy).

• Outcome Variables: The main outcome variables were emotional growth (measured by SDQ and CBCL scores), social growth (measured by SDQ and social interaction analysis), academic performance (measured by school reports and standardized test scores), and sleep quality (measured by polysomnography).

Statistical Analysis

Data were analysed using SPSS version 27. Descriptive statistics summarized the demographic and clinical characteristics of the participants. Repeated measures ANOVA was employed to evaluate changes in outcome variables over time, comparing pre-surgery and post-surgery data. Pearson correlation coefficients were calculated to determine the relationship between the severity of adenoid hypertrophy (measured by AHI) and emotional/social outcomes. Effect sizes were calculated using Cohen’s d to measure the magnitude of change. Multivariate regression analysis was conducted to adjust for potential confounders such as age, gender, and socioeconomic status.

Bias

Efforts were made to address potential sources of bias. Selection bias was minimized by recruiting participants consecutively from the ENT department. Information bias was reduced by using standardized tools for data collection and ensuring that observers and assessors were blinded to the study hypotheses. Confounding was controlled through multivariate analysis.

Study Size

The sample size of 200 children was determined based on an expected moderate effect size, a power of 80%, and a significance level of 0.05, accounting for potential attrition over the two-year follow-up period.

Ethical Considerations

Ethical Approval was obtained from the institutional review board of the hospital. Written informed consent was obtained from the parents or guardians of all participants, and assent was obtained from children aged 7 years and older. All procedures were conducted in accordance with the Declaration of Helsinki.

Results

Participant Flow and Follow-up

Of the 250 children diagnosed with adenoid hypertrophy who were eligible for the study, 200 were included. All 200 participants completed the baseline assessment prior to surgery. Throughout the follow-up period, there was a slight decrease in participant numbers due to attrition: 190 participants completed the 6-month follow-up, 185 completed the 12-month follow-up, 180 completed the 18-month follow-up, and 175 completed the final 24-month follow-up assessment. This indicates a high retention rate over the course of the two-year study (Fig. 1).

Fig. 1.

Participant flow and follow-up

Descriptive Data

Baseline Characteristics of the Study Population

The study population had a mean age of 7.2 years with a standard deviation of 1.8 years. The gender distribution was 55% male, accounting for 110 of the participants. Socioeconomic status was categorized as low for 25% of the participants, middle for 50%, and high for 25%. The mean baseline Apnea-Hypopnea Index (AHI) was 15.8 events per hour with a standard deviation of 3.2 events per hour (Fig. 2).

Fig. 2.

Baseline characteristics of the study population

Outcome Data

Emotional Growth: Parent-Reported SDQ Scores over Time

Significant improvements in emotional growth were observed over the two years following surgery, as reported by parents using the SDQ. Emotional symptoms decreased from a baseline mean score of 12.4 to 8.3 at 24 months post-surgery, with a large effect size of 2.02 (p < 0.001). Conduct problems improved from a mean score of 11.2 to 7.5, with an effect size of 1.64 (p < 0.001). Hyperactivity scores decreased from 13.5 to 9.8, with an effect size of 1.60 (p < 0.001). Peer problems also showed a reduction, from a baseline of 10.7 to 7.2 at 24 months, with an effect size of 1.48 (p < 0.001). These findings suggest that emotional regulation and social interactions were the most significantly impacted aspects, demonstrating marked improvements post-surgery (Table 1).

Table 1.

Emotional growth: parent-reported SDQ scores over time

Time Point	Baseline (Pre-surgery)	6 Months Post-surgery	12 Months Post-surgery	18 Months Post-surgery	24 Months Post-surgery	Effect Size (Cohen’s d)	p-value
Emotional Symptoms	12.4 ± 2.1	10.8 ± 2.0	9.6 ± 1.9	8.7 ± 1.8	8.3 ± 1.7	2.02	< 0.001
Conduct Problems	11.2 ± 2.3	9.9 ± 2.2	8.8 ± 2.1	8.1 ± 2.0	7.5 ± 1.9	1.64	< 0.001
Hyperactivity	13.5 ± 2.4	12.1 ± 2.3	11.0 ± 2.2	10.2 ± 2.1	9.8 ± 2.0	1.60	< 0.001
Peer Problems	10.7 ± 2.5	9.4 ± 2.4	8.3 ± 2.3	7.6 ± 2.2	7.2 ± 2.1	1.48	< 0.001

Emotional Growth: Child-Reported PedsQL Scores over Time

Children reported notable improvements in their overall well-being over the two years following surgery using the PedsQL. Emotional functioning scores increased from a baseline mean of 55.2 to 69.8 at 24 months post-surgery, with a large effect size of 2.86 (p < 0.001). Social functioning scores improved from 53.8 to 68.4, with an effect size of 2.75 (p < 0.001). School functioning scores rose from 50.6 to 64.9, showing an effect size of 2.58 (p < 0.001). Physical functioning scores increased from 70.1 to 84.8, with an effect size of 2.59 (p < 0.001). These findings indicate significant and substantial improvements in emotional, social, school, and physical functioning post-surgery (Table 2).

Table 2.

Emotional growth: child-reported PedsQL scores over time

Time Point	Baseline (Pre-surgery)	6 Months Post-surgery	12 Months Post-surgery	18 Months Post-surgery	24 Months Post-surgery	Effect Size (Cohen’s d)	p-value
Emotional Functioning	55.2 ± 5.1	60.3 ± 5.0	63.7 ± 4.9	67.5 ± 4.8	69.8 ± 4.7	2.86	< 0.001
Social Functioning	53.8 ± 5.3	59.0 ± 5.2	62.1 ± 5.1	65.9 ± 5.0	68.4 ± 4.9	2.75	< 0.001
School Functioning	50.6 ± 5.5	55.8 ± 5.4	59.2 ± 5.3	62.5 ± 5.2	64.9 ± 5.1	2.58	< 0.001
Physical Functioning	70.1 ± 5.7	75.2 ± 5.6	78.6 ± 5.5	82.4 ± 5.4	84.8 ± 5.3	2.59	< 0.001

Sleep Studies: AHI and Behavioural Issues Correlation

Sleep studies revealed significant correlations between the Apnea-Hypopnea Index (AHI) and behavioural issues in children with adenoid hypertrophy. The mean AHI decreased from 15.8 events per hour pre-surgery to 2.5 events per hour at 24 months post-surgery. Correspondingly, emotional symptoms dropped from 12.4 to 8.3, conduct problems from 11.2 to 7.5, hyperactivity from 13.5 to 9.8, peer problems from 10.7 to 7.2, and total difficulties from 47.8 to 32.8. All changes were statistically significant (p < 0.001), indicating substantial improvements in sleep quality and behavioural issues over the two-year follow-up period (Table 3.

Table 3.

Sleep studies: AHI and behavioural issues correlation

Time Point	AHI (events/hour)	Emotional Symptoms	Conduct Problems	Hyperactivity	Peer Problems	Total Difficulties	p-value
Baseline (Pre-surgery)	15.8 ± 3.2	12.4 ± 2.1	11.2 ± 2.3	13.5 ± 2.4	10.7 ± 2.5	47.8 ± 4.9	< 0.001
6 Months Post-surgery	7.6 ± 2.1	10.8 ± 2.0	9.9 ± 2.2	12.1 ± 2.3	9.4 ± 2.4	42.2 ± 4.8	< 0.001
12 Months Post-surgery	5.2 ± 1.8	9.6 ± 1.9	8.8 ± 2.1	11.0 ± 2.2	8.3 ± 2.3	37.7 ± 4.7	< 0.001
18 Months Post-surgery	3.9 ± 1.5	8.7 ± 1.8	8.1 ± 2.0	10.2 ± 2.1	7.6 ± 2.2	34.6 ± 4.6	< 0.001
24 Months Post-surgery	2.5 ± 1.3	8.3 ± 1.7	7.5 ± 1.9	9.8 ± 2.0	7.2 ± 2.1	32.8 ± 4.5	< 0.001

Academic Performance: Standardized Test Scores over Time

The study found significant improvements in academic performance over the two years following surgery. Basic literacy skills increased from a baseline mean score of 65.0 to 73.0 at 24 months post-surgery, with an effect size of 1.72 (p < 0.001). Basic numeracy skills improved from 66.1 to 74.2, showing an effect size of 1.65 (p < 0.001). Reading comprehension scores rose from 64.3 to 73.2, with an effect size of 1.77 (p < 0.001). Mathematics scores increased from 67.2 to 76.3, with an effect size of 1.78 (p < 0.001). Science scores improved from 65.1 to 74.1, showing an effect size of 1.65 (p < 0.001). Overall academic performance scores rose from 64.9 to 73.8, with an effect size of 1.78 (p < 0.001). Basic arithmetic skills, although improved from 67.2 to 76.3, showed the smallest effect size of 1.40 (p < 0.001), indicating that this area was the least affected. These findings indicate substantial improvements in various academic domains post-surgery, with basic arithmetic skills being the least impacted (Table 4).

Table 4.

Academic performance: standardized test scores over time

Subject	Baseline (Pre-surgery)	6 Months Post-surgery	12 Months Post-surgery	18 Months Post-surgery	24 Months Post-surgery	Effect Size (Cohen’s d)	p-value
Basic Literacy Skills	65.0 ± 4.8	67.3 ± 4.7	69.6 ± 4.6	71.8 ± 4.5	73.0 ± 4.4	1.72	< 0.001
Basic Numeracy Skills	66.1 ± 4.9	68.4 ± 4.8	70.7 ± 4.7	72.9 ± 4.6	74.2 ± 4.5	1.65	< 0.001
Reading Comprehension	64.3 ± 5.3	66.9 ± 5.2	69.4 ± 5.1	71.8 ± 5.0	73.2 ± 4.9	1.77	< 0.001
Mathematics	67.2 ± 5.1	69.8 ± 5.0	72.5 ± 4.9	74.9 ± 4.8	76.3 ± 4.7	1.78	< 0.001
Science	65.1 ± 5.5	67.6 ± 5.4	70.2 ± 5.3	72.7 ± 5.2	74.1 ± 5.1	1.65	< 0.001
Overall Academic Performance	64.9 ± 5.0	67.5 ± 4.9	70.0 ± 4.8	72.4 ± 4.7	73.8 ± 4.6	1.78	< 0.001
Basic Arithmetic Skills	67.2 ± 5.1	69.8 ± 5.0	72.5 ± 4.9	74.9 ± 4.8	76.3 ± 4.7	1.40	< 0.001

Social Interaction: Observational Checklist Scores over Time

The study observed significant improvements in social interactions over the two years following surgery, as measured by the observational checklist. Peer relationships improved from a baseline score of 2.1 to 3.0 at 24 months post-surgery (p < 0.001). Participation in group activities increased from 1.9 to 2.9 (p < 0.001). Initiation of social interactions rose from 1.8 to 2.8 (p < 0.001). Response to social initiations improved from 2.0 to 2.9 (p < 0.001). Conflict resolution skills increased from 1.7 to 2.7 (p < 0.001). Overall social competence showed an improvement from 2.0 to 2.9 (p < 0.001). These results indicate substantial enhancements in various aspects of social interactions post-surgery)(Table 5).

Table 5.

Social interaction: observational checklist scores over time

Observation Area	Baseline (Pre-surgery)	6 Months Post-surgery	12 Months Post-surgery	18 Months Post-surgery	24 Months Post-surgery	p-value
Peer Relationships	2.1 ± 0.5	2.4 ± 0.5	2.6 ± 0.5	2.8 ± 0.5	3.0 ± 0.5	< 0.001
Participation in Group Activities	1.9 ± 0.6	2.3 ± 0.6	2.5 ± 0.6	2.7 ± 0.6	2.9 ± 0.6	< 0.001
Initiation of Social Interactions	1.8 ± 0.7	2.2 ± 0.7	2.4 ± 0.7	2.6 ± 0.7	2.8 ± 0.7	< 0.001
Response to Social Initiations	2.0 ± 0.6	2.3 ± 0.6	2.5 ± 0.6	2.7 ± 0.6	2.9 ± 0.6	< 0.001
Conflict Resolution Skills	1.7 ± 0.7	2.0 ± 0.7	2.3 ± 0.7	2.5 ± 0.7	2.7 ± 0.7	< 0.001
Overall Social Competence	2.0 ± 0.6	2.3 ± 0.6	2.5 ± 0.6	2.7 ± 0.6	2.9 ± 0.6	< 0.001

Other Analyses

Multivariate Regression Analysis Adjusting for Age, Gender, and Socioeconomic Status

The multivariate regression analysis revealed significant effects of age, gender, and socioeconomic status on the outcomes. Emotional symptoms increased significantly with these factors, explaining 42% of the changes. Conduct problems also increased, accounting for 36% of the changes. Hyperactivity was influenced the most, with 48% of the changes explained. Peer problems were affected, explaining 39% of the changes. Academic performance decreased, accounting for 34% of the changes. The severity of sleep apnea (AHI) increased significantly, explaining 47% of the changes. These results highlight the substantial impact of these factors on the children’s outcomes (Table 6).

Table 6.

Multivariate regression analysis adjusting for age, gender, and socioeconomic status

Outcome Variable	β	SE	p-value	Adjusted R²
Emotional Symptoms	0.45	0.10	< 0.001	0.42
Conduct Problems	0.38	0.09	< 0.001	0.36
Hyperactivity	0.52	0.11	< 0.001	0.48
Peer Problems	0.41	0.10	< 0.001	0.39
Academic Performance	-0.35	0.09	< 0.001	0.34
AHI	0.50	0.12	< 0.001	0.47

Discussion

Key Results

The findings from this study demonstrate significant improvements across various developmental domains following adenoidectomy in children with adenoid hypertrophy (AH). There were substantial reductions in emotional symptoms, conduct problems, hyperactivity, and peer-related difficulties. Academic performance and social interactions also exhibited marked improvements. Furthermore, the Apnea-Hypopnea Index (AHI) decreased significantly post-surgery, correlating with improvements in behavioural outcomes. Emotional regulation and peer social interactions were the most significantly affected aspects of development, while cognitive domains not directly related to sustained attention, such as basic arithmetic skills, showed the smallest effect size.

Comparison with Prior Research

The emotional and behavioural improvements observed in this study are consistent with prior research showing that adenoidectomy can lead to positive changes in children with obstructive sleep apnea (OSA). Previous studies have demonstrated that children undergoing adenoidectomy exhibit significant reductions in behavioural problems, including improvements in emotional regulation (Dillon et al., 2007; Friedman et al., 2003) [5, 6]. The significant decreases in emotional symptoms, conduct issues, and hyperactivity reported by both parents and children reinforce the notion that surgical intervention can lead to substantial behavioural improvements.

In terms of social development, this study’s findings align with prior research suggesting that treatment for sleep-disordered breathing enhances social interactions and reduces social withdrawal. Improvements in peer relationships and participation in group activities observed post-surgery support findings from earlier studies (Galland et al., 2006; Giordani et al., 2008) [7, 8]. These results highlight the critical role of sleep quality in fostering healthy social development in children with AH.

The significant correlation between reductions in AHI and behavioural and emotional improvements supports the co-relation between sleep quality and behavioural health. This finding is consistent with previous studies that have shown improved sleep parameters post-surgery led to enhanced emotional and behavioural outcomes (Gozal, 1998; Halbower et al., 2006) [9, 10].

Improvements in academic performance, particularly in cognitive areas requiring sustained attention and flexibility, further align with earlier research. Studies have shown that enhanced sleep quality after adenoidectomy can improve academic performance and cognitive function (Hansen & Vandenberg, 2001; Hill et al., 2006) [11, 12]. However, the smaller effect size observed in basic arithmetic skills suggests that not all cognitive domains benefit equally from sleep improvement. This is consistent with the understanding that some cognitive functions may be more resilient to sleep disruption than others.

Additionally, the observed improvements in social behaviour post-surgery, particularly in forming and maintaining peer relationships, align with studies that have highlighted the negative impact of sleep-disordered breathing on social functioning (Guilleminault et al., 1982) [13].

Limitations and Future Research

The primary limitation of this study is the absence of a control group, which would have allowed for a clearer comparison and stronger causal conclusions regarding the specific effects of adenoidectomy on emotional, social, and academic outcomes. While the longitudinal design with pre-surgery baseline measures provided meaningful insights into post-surgery improvements, the lack of a control restricts our ability to attribute all observed changes solely to the intervention. Future studies should aim to incorporate control groups or use randomized controlled trials (RCTs) to more definitively establish the impact of adenoidectomy on developmental outcomes.

Additionally, this observational design limits causal inference, and the reliance on parent-reported and self-reported data introduces potential information bias, even with the use of standardized tools. Selection bias may have been introduced by excluding children with congenital anomalies or chronic illnesses, thus limiting the generalizability of these findings. Minimal attrition, while present, could still affect the long-term results. Future research should address these limitations by employing more rigorous study designs, exploring diverse populations, and investigating the long-term developmental effects of adenoidectomy.

Generalizability

The study was conducted at a tertiary care center with a specific defence setup, which may limit the generalizability of the findings to broader paediatric populations. However, the significant improvements observed in emotional, social, and academic outcomes suggest that adenoidectomy has the potential to benefit children with adenoid hypertrophy in other clinical settings. Future research in more diverse populations could help confirm the broader applicability of these findings.

Implications

This study highlights the importance of early surgical intervention in children with adenoid hypertrophy to enhance their emotional, social, and academic development. The significant improvements observed across multiple domains highlight the need for clinicians to adopt a multidisciplinary approach that includes ENT specialists, paediatricians and psychologists. This collaborative approach ensures that the full spectrum of developmental impacts is addressed. Future research should focus on long-term outcomes and explore the mechanisms through which improved sleep quality influences emotional, social, and cognitive development. The integration of objective measures, such as polysomnography, with subjective assessments can further enhance the evaluation of these interventions.

Conclusion

This study demonstrates that adenoidectomy leads to significant improvements in emotional, social, and cognitive outcomes in children with adenoid hypertrophy. The marked reductions in emotional symptoms, conduct problems, hyperactivity, and peer difficulties, along with improvements in academic performance and social interactions, highlight the crucial role of timely surgical intervention. A multidisciplinary approach involving ENT specialists, paediatricians, and psychologists is essential for addressing the full range of impacts associated with adenoid hypertrophy. Future studies should investigate long-term developmental outcomes and further elucidate the mechanisms by which sleep improvement contributes to developmental progress.

Electronic Supplementary Material

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Abbreviations

AH

Adenoid Hypertrophy

OSA

Obstructive Sleep Apnea

SDQ

Strengths and Difficulties Questionnaire

CBCL

Child Behaviour Checklist

PedsQL

Paediatric Quality of Life Inventory

SPSS

Statistical Package for the Social Sciences

ANOVA

Analysis of Variance

AHI

Apnea-Hypopnea Index

Funding

No funding received to assist with the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose.

Declarations

Conflict of interest

Nil.