ABSTRACT
Objective
To investigate the relationship between parental anxiety and postoperative pain and complications in children undergoing adenotonsillectomy.
Methods
The level of pain of the child and the pain perceived by the parent were questioned using the Wong‐Baker FACESR pain grading scale at postoperative 6 hour, 24 hour, 1 week, and 2 weeks. For evaluation of the anxiety status of the parents, the following questionnaires were used: the State–Trait Anxiety Inventory (STAI), the Anxiety Sensitivity Index‐3 (ASI‐3) and the parent version of the Pain Catastrophizing Scale (PCS‐P). Using the State Anxiety scores, the parents were classified into three groups. The patients were followed up in respect to complications (fever, nausea‐vomiting, re‐hospitalization, re‐operation).
Results
Evaluations were made of 145 patients and their parents. Of the total parents, mild anxiety was determined in 47 (32.4%) (Group 1), moderate anxiety in 70 (48.2%) (Group 2), and severe anxiety in 28 (19.3%) (Group 3). Pearson correlation analysis showed a positive correlation between parental anxiety and the pain scores of both the parents and the children. Complications developed in 1 (2.1%) patient in Group 1, in 22 (31.4%) in Group 2, and in 16 (57.1%) in Group 3 (p = 0.0001).
Conclusion
The results of this study demonstrated that postoperative pain and complications were seen at a higher rate in children undergoing adenotonsillectomy whose parents had a high level of anxiety. Preoperative psychosocial support given to parents could reduce pain and complications to lower levels.
Level of Evidence
3.
Trial Registration: NCT06579586
Keywords: adenotonsillectomy, complications, parental anxiety, pediatric otolaryngology, postoperative pain
The aim of this study was to investigate the relationship between parental anxiety and postoperative pain and complications in children undergoing adenotonsillectomy. The results of the current study showed that the pain scores and complication rates of the children of parents with severe anxiety were higher. As parental anxiety increased, so the postoperative pain scores of both the children and the parents increased. Preoperative psychosocial support given to parents could reduce pain and complications to lower levels.
1. Introduction
Adenotonsillectomy is one of the most frequently performed surgical procedures in children. It is indicated in children who experience recurrent adenotonsillitis or who have obstructive symptoms. There are complications of this operation, such as prolonged postoperative pain, swallowing difficulty, infection, and bleeding. Prolonged postoperative pain can potentially cause reduced oral intake, dehydration, dysphagia, and even hospital re‐admission [1].
The postoperative recovery process in children is affected not only by medical factors but also by psychosocial factors. Therefore, it is thought that the preoperative psychological status and level of anxiety of parents play a determining role in the postoperative experience of children [2]. Recent research has shown that high anxiety of parents preoperatively can directly affect postoperative pain levels and the recovery process of children [2, 3]. Parental psychological factors are also thought to have an impact on differences in the subject of pain perception and management. According to a previous study, the level to which pain is catastrophised by parents in the preoperative period is directly related to the postoperative pain experiences of children. Esteve et al. reported that the children of parents with a high anxiety level obtained higher pain scores, and negative perceptions of pain were more common. Moreover, the emotional and behavioral responses during postoperative recovery and the pain management of the children could be directly affected by these parents [4]. However, it has also been stated that obstructive symptoms in the children and the development of apnea increased anxiety in the parents, and this anxiety could constitute an additional stress factor in surgical procedures. In the study by Kljajic et al. high levels of anxiety and stress were observed in the parents, especially the mothers, of children diagnosed with obstructive sleep apnea syndrome (OSAS), and following adenotonsillectomy this anxiety and stress were determined to have decreased. That study emphasized that the recovery of the health of the child was positively reflected in the psychological status of the parents, but a high preoperative stress level can have a negative effect on the postoperative recovery of the child [5].
Studies in the literature that have examined the effect of parental anxiety on children undergoing adenotonsillectomy are both few in number and have included few patients [2, 3, 4, 5]. To the best of our knowledge, none of these studies have evaluated the effect of parental anxiety on postoperative complications. Therefore, the aim of this study was to investigate the relationship between parental anxiety and postoperative pain and complications in children undergoing adenotonsillectomy.
2. Materials and Methods
This study was conducted in our clinic between August and December 2024. All procedures were in accordance with the ethical principles of the Helsinki Declaration, and patient rights were protected (14.08.2024/AEŞH‐BADEK‐2024‐775). The study was registered with clinical trials number NCT06579586. Written informed consent was provided by the parents of all the patients. The study included patients aged 4–14 years who presented at the Ear, Nose, and Throat Outpatient Clinic with obstructive symptoms such as snoring, witnessed apnea, mouth breathing, and hyponasal speech and were diagnosed with adenotonsillar hypertrophy from direct visual and endoscopic examination, or presented with the complaint of frequent throat infections and were diagnosed with recurrent adenotonsillitis, and finally underwent adenotonsillectomy. Patients were excluded from the study if they had any craniofacial or genetic anomaly, a bleeding disorder or disease, any psychiatric or mental health disease, or history of drug use in the parent or child, patients who could not speak Turkish, or those who wished to withdraw from the study at any stage. The demographic data of the children and parents were recorded together with information related to previous anesthesia and surgical procedures of the children.
2.1. Questionnaires Evaluating Anxiety
The parents were evaluated 1–2 hour before the child was admitted for surgery. All the parents were questioned about whether they had any doubts about the operation and/or postoperative care. For evaluation of the anxiety status of the parents, the following questionnaires were used: the State–Trait Anxiety Inventory (STAI) [6], the Anxiety Sensitivity Index‐3 (ASI‐3) [7, 8] and the parent version of the Pain Catastrophizing Scale (PCS‐P) [9, 10]. The STAI, which is widely used in clinical settings to diagnose anxiety, consists of two sections evaluating “state” and “trait” anxiety. The first 20 items evaluate State anxiety, that is, anxiety at a given moment under certain conditions, using items that measure feelings of apprehension, tension, worry, and nervousness at the given time. The second 20 items evaluate Trait anxiety, or baseline anxiety, including general states of calmness, confidence, and security. The ASI‐3 consists of a total of 18 items in three subscales of Physical, Social, and Cognitive, with six items in each. It is scored on a 5‐point Likert type scale where 0 = very little and 4 = a lot. The PCS‐P is a 13‐item self‐administered questionnaire in which the subjects are asked to classify the frequency at which they experience the thoughts listed. Items are scored on a 5‐point scale, ranging from 0 (never) to 4 (always), to provide a total score of 0–52 points. Using the STAI, State Anxiety of the parents was evaluated and classified in three groups according to the scores: Group 1: 20–39 points, mild anxiety; Group 2: 40–59 points, moderate anxiety; Group 3: 60–79 points, severe anxiety. Trait anxiety of the groups was also evaluated. The physical, cognitive, and mental sub‐dimension scores of the ASI‐3 were analyzed separately in the groups. The groups were also analyzed separately in respect of the rumination, magnification, and helplessness sub‐dimensions of the PCS‐P. In the 2nd week postoperatively, the parents were questioned about whether they had allowed the child to return to school.
2.2. Postoperative Pain Evaluation
Evaluation of pain in both the children and the parents was made using the Wong‐Baker FACESR pain grading scale (Figure 1) [11]. The level of pain of the child and the pain perceived by the parent were questioned using this scale at postoperative 6 hour, 24 hour, 1 week, and 2 weeks. To avoid the parent influencing the child when being questioned about pain, the child was asked first and then the parent. On discharge from the hospital, all the children were prescribed paracetamol (10–15 mg/kg) and ibuprofen (5–10 mg/kg) syrup.
FIGURE 1.
Wong‐Baker FACESR pain rating scale. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
2.3. Operation Room (OR) and Post‐Anesthesia Care Unit
Only one of the parents accompanied his or her child as far as the operating theater. In the pre‐anesthesia care unit, according to the experience of the anesthesia specialist, oral premedication (midazolam 0.15 mg/kg) was administered when necessary to the child while the parent was present. When the child was then seen to be calm, the parent was taken to the waiting room. All the adenotonsillectomy operations were performed by an experienced surgical team (SD, BVC, SO). Orotracheal intubation with an endotracheal tube was performed under general anesthesia. The mouth was opened with a Davis‐Boyle mouth opener. Adenoid tissue was removed with an adenoid curette, then checked with palpation, and surgical curettage was repeated until it was ensured to be sufficient. Hemostasis of the adenoidectomy region was provided with a prepared sponge pad (5–8 min), and for bleeding that continued after removal of the pad, bipolar cauterisation was used. Tonsillectomy was then performed with subcapsular dissection of the tonsil from the superior pole towards the inferior pole. The tonsils were dissected with cold dissection applied from the muscle wall towards the inferior pole. Then the tonsils were completely removed from the tonsillar fossa. Electrocauterisation with bipolar cautery was used to provide hemostasis. It was recorded whether or not dexamethasone (0.5 mg/kg) and/or paracetamol (10–15 mg/kg) was administered to the children perioperatively according to the experience of the anesthesia specialist. Postoperatively, all the patients were observed for at least 30 min in the Post‐anesthesia Care Unit because of the possibility of side effects. The patients were then followed up in respect of complications (fever, nausea‐vomiting, re‐hospitalization, re‐operation).
2.4. Statistical Analyses
The data obtained were analyzed using PASW 18 software (SPSS/IBM, Chicago, IL, USA). Descriptive statistics were presented as mean ± standard deviation (SD) values for continuous data with normal distribution, and as number (n) and percentage (%) for categorical data. The significance of differences in mean values between the groups was investigated with a One Way ANOVA test (Post Hoc‐Bonferroni). The Chi‐square test was used in the comparisons of categorical variables. The relationship between parental anxiety and the postoperative pain scores was evaluated with Pearson correlation analysis. A value of p < 0.05 was considered statistically significant.
3. Results
Evaluations were made of 145 patients and their parents. Of the total parents, mild anxiety was determined in 47 (32.4%) (Group 1), moderate anxiety in 70 (48.2%) (Group 2), and severe anxiety in 28 (19.3%) (Group 3). The mean age of the patients was 7.45 ± 3.11 years in Group 1, 6.77 ± 2.3 years in Group 2, and 6.68 ± 2.63 years in Group 3 (p = 0.32). The parents accompanying the children were 33 (70.2%) mothers and 14 (29.8%) fathers in Group 1, 53 (75.7%) mothers and 17 (24.3%) fathers in Group 2, and 18 (64.3%) mothers and 10 (35.7%) fathers in Group 3 (p = 0.50). The comparisons of the demographic data of the groups (patient gender, parent age, parent gender, marital status of parents, total family income, etc.) are shown in Table 1.
TABLE 1.
Comparisons of the demographic data of the children and parents.
| Group 1 mild anxiety (n = 47) | Group 2 moderate anxiety (n = 70) | Group 3 severe anxiety (n = 28) | p | |
|---|---|---|---|---|
| Child age (years) (mean + SD) | 7.45 ± 3.11 | 6.77 ± 2.3 | 6.68 ± 2.63 | 0.32 b |
| Gender (male/female) | 29 (61.7%)/18 (38.3%) | 40 (57.1%)/30 (42.9%) | 12 (42.9%)/16 (57.1%) | 0.27 a |
| Parent age (years) (mean + SD) | 34.04 ± 5.1 | 35.36 ± 5.4 | 34.82 ± 7 | 0.47 b |
| Parent gender (mother/father) | 33 (70.2%)/14 (29.8%) | 53 (75.7%)/17 (24.3%) | 18 (64.3%)/10 (35.7%) | 0.50 a |
| Marital status (married/single) | 45 (95.7%)/2 (4.3%) | 68 (97.1%)/2 (2.9%) | 28 (100%)/0 (0%) | 0.55 a |
| Number of children (mean + SD) | 2.4 ± 0.87 | 2.3 ± 1.07 | 2.1 ± 0.84 | 0.53 b |
| Education level (primary school/university‐postgraduate) | 36 (76.6%)/11 (23.4%) | 54 (77.1%)/16 (22.9%) | 23 (82.1%)/5 (17.9%) | 0.53 a |
| Total family income (< 20.000TL/20–50.000TL/> 50.000TL) | 10 (21.3%)/26 (55.3%)/11 (23.4%) | 20 (28.6%)/33 (47.2%)/17 (24.2%) | 10 (35.7%)/14 (50%)/4 (14.2%) | 0.60 a |
| School attended by the child (none/state/private) | 10 (21.3%)/36 (76.6%)/1 (2.1%) | 11 (15.7%)/54 (77.1%)/5 (7.2%) | 5 (17.9%)/20 (71.4%)/3 (10.7%) | 0.58 a |
| Operation history of the child (yes/no) | 8 (17%)/39 (83%) | 9 (12.9%)/61 (87.1%) | 4 (14.3%)/24 (85.7%) | 0.82 a |
| ASA c (American Society of Anesthesiologists) score (I/II) | 42 (89.4%)/5 (10.6%) | 63 (90%)/7 (10%) | 23 (82.1%)/5 (17.9%) | 0.52 a |
| Preoperative oral midazolam intake (yes/no) | 31 (66%)/16 (34%) | 54 (77.1%)/16 (22.9%) | 19 (67.9%)/9 (32.1%) | 0.37 a |
| Perioperative medication (none/analgesic/steroid/analgesic + steroid) | 1 (2.1%)/44 (93.6%)/0 (0%)/2 (4.3%) | 3 (4.3%)/59 (84.3%)/2 (2.9%)/6 (8.6%) | 0 (0%)/25 (89.3%)/1 (3.6%)/2 (7.1%) | 0.68 a |
| Postoperative length of stay in hospital (days) (mean + SD) | 1.34 ± 0.73 | 1.29 ± 0.74 | 1.46 ± 0.96 | 0.59 b |
Chi‐square test.
One way ANOVA test.
American Society of Anesthesiologists, Committee on Economics. ASA Physical Status Classification System. https://www.asahq.org/standards‐and‐guidelines/asa‐physical‐status‐classification‐system. Last amended December 13, 2020.
In the STAI‐Trait Anxiety Inventory evaluating the anxiety status of the parents, the scores were determined to be 39.23 ± 8.36 in Group 1, 46.13 ± 8.9 in Group 2, and 64.39 ± 9.37 in Group 3 (p = 0.0001). The comparisons of the ASI‐3 and the PCS‐P are shown in Table 2. When Bonferroni correction was applied, with the exception of PCS‐P Rumination and PCS‐P Helplessness, the p values were statistically significant in all the paired comparisons for STAI‐Trait Anxiety, ASI‐3 Cognitive, ASI‐3 Physical, ASI‐3 Social, and PCS‐P Magnification (Groups 1–2, Groups 2–3, Groups 1–3). The scores for PCS‐P Rumination and PCS‐P Helplessness were similar in Group 2 and Group 3 and significantly lower in Group 1 than in the other two groups (Table 3).
TABLE 2.
Comparisons of the anxiety questionnaire results of the groups.
| Group 1‐mild anxiety (n = 47) (mean + SD) | Group 2‐moderate anxiety (n = 70) (mean + SD) | Group 3‐severe anxiety (n = 28) (mean + SD) | p | |
|---|---|---|---|---|
| STAI trait anxiety | 39.23 ± 8.36 | 46.13 ± 8.9 | 64.39 ± 9.37 | 0.0001 a |
| ASI‐3 cognitive b | 8.11 ± 3.82 | 12.49 ± 7.38 | 16.29 ± 7.87 | 0.0001 a |
| ASI‐3 physical b | 9.19 ± 4.67 | 12.63 ± 6.77 | 16.32 ± 7.0 | 0.0001 a |
| ASI‐3 social b | 7.70 ± 3.95 | 11.66 ± 7.08 | 16.04 ± 7.72 | 0.0001 a |
| PCS‐P rumination c | 8.15 ± 2.93 | 11.19 ± 4.34 | 13.18 ± 4.73 | 0.0001 a |
| PCS‐P magnification c | 6.49 ± 2.91 | 10.06 ± 4.73 | 13.25 ± 4.17 | 0.0001 a |
| PCS‐P helplessness c | 11.15 ± 5.23 | 13.86 ± 4.95 | 15.93 ± 4.58 | 0.0001 a |
One way ANOVA test.
ASI‐3: anxiety sensitivity index‐3.
PCS‐P: pain catastrophizing scale‐parents.
TABLE 3.
Paired comparisons of the anxiety and pain scores of the groups.
| Group 1‐mild anxiety, group 2‐moderate anxiety, group 3‐severe anxiety | p | 95% CI (lower/upper) c | ||
|---|---|---|---|---|
| STAI trait anxiety | Group 1 | Group 2 | 0.0001 | −10.93/−2.86 |
| Group 3 | 0.0001 | −30.26/−20.06 | ||
| Group 2 | Group 3 | 0.0001 | −23.04/−13.48 | |
| ASI‐3 cognitive a | Group 1 | Group 2 | 0.002 | −7.38/−1.38 |
| Group 3 | 0.0001 | −11.98/−4.38 | ||
| Group 2 | Group 3 | 0.032 | −7.36/−0.24 | |
| ASI‐3 physical a | Group 1 | Group 2 | 0.012 | −6.28/−0.60 |
| Group 3 | 0.0001 | −10.73/−3.53 | ||
| Group 2 | Group 3 | 0.026 | −7.06/−0.32 | |
| ASI‐3 social a | Group 1 | Group 2 | 0.004 | −6.87/−1.04 |
| Group 3 | 0.0001 | −12.03/−4.64 | ||
| Group 2 | Group 3 | 0.008 | −7.84/−0.92 | |
| PCS‐P rumination b | Group 1 | Group 2 | 0.0001 | −4.88/−1.20 |
| Group 3 | 0.0001 | −7.36/−2.70 | ||
| Group 2 | Group 3 | 0.086 | −4.18/0.19 | |
| PCS‐P magnification b | Group 1 | Group 2 | 0.0001 | −5.45/−1.69 |
| Group 3 | 0.0001 | −9.14/−4.38 | ||
| Group 2 | Group 3 | 0.002 | −5.42/−0.96 | |
| PCS‐P helplessness b | Group 1 | Group 2 | 0.014 | −4.98/−0.43 |
| Group 3 | 0.0001 | −7.66/−1.90 | ||
| Group 2 | Group 3 | 0.195 | −4.77/0.63 | |
| Postoperative pain scores | ||||
| 6 hour child | Group 1 | Group 2 | 1.000 | −1.08/0.78 |
| Group 3 | 0.0001 | −3.24/−0.89 | ||
| Group 2 | Group 3 | 0.0001 | −3.02/−0.81 | |
| 6 hour parent | Group 1 | Group 2 | 0.019 | −1.94/−0.13 |
| Group 3 | 0.0001 | −4.29/−2.0 | ||
| Group 2 | Group 3 | 0.0001 | −3.19/−1.04 | |
| 24 hour parent | Group 1 | Group 2 | 0.10 | −1.89/0.13 |
| Group 3 | 0.0001 | −3.51/−0.96 | ||
| Group 2 | Group 3 | 0.02 | −2.55/−0.16 | |
| 1 week child | Group 1 | Group 2 | 0.08 | −1.31/0.06 |
| Group 3 | 0.03 | −1.79/−0.06 | ||
| Group 2 | Group 3 | 1.000 | −1.11/0.51 | |
| 1 week parent | Group 1 | Group 2 | 0.02 | −1.74/−0.08 |
| Group 3 | 0.001 | −2.71/−0.62 | ||
| Group 2 | Group 3 | 0.1 | −1.74/0.22 | |
| 2 weeks child | Group 1 | Group 2 | 0.02 | −0.92/−0.05 |
| Group 3 | 0.009 | −1.24/−0.14 | ||
| Group 2 | Group 3 | 1.000 | −0.71/0.31 | |
| 2 weeks parent | Group 1 | Group 2 | 0.001 | −1.41/−0.27 |
| Group 3 | 0.0001 | −2.22/−0.78 | ||
| Group 2 | Group 3 | 0.06 | −1.33/0.02 | |
Note: Bold indicates significant values.
Abbreviation: CI: confidence interval.
ASI‐3: anxiety sensitivity index‐3.
PCS‐P: pain catastrophizing scale‐ parents.
One way ANOVA test (post hoc test‐Bonferroni correction).
The mean pain scores of the children at postoperative 6 hour were determined to be 5.36 ± 1.96 in Group 1, 5.51 ± 1.99 in Group 2, and 6.68 ± 2.63 in Group 3 (p = 0.0001). The scores of the pain perceived by the parents at 6 hour postoperatively were 4.85 ± 2.07 in Group 1, 5.89 ± 2.09 in Group 2, and 8 ± 1.44 in Group 3 (p = 0.0001). The pain scores at 24 hour, 1 week, and 2 weeks for the children and the parents are summarized in Table 4. Pearson correlation analysis showed a positive correlation between parental anxiety and the pain scores of both the parents and the children (Table 5).
TABLE 4.
Comparisons of the pain scores of the children and parents.
| Postoperative pain scores | Group 1‐mild anxiety (n = 47) (mean + SD) | Group 2‐moderate anxiety (n = 70) (mean + SD) | Group 3‐severe anxiety (n = 28) (mean + SD) | p |
|---|---|---|---|---|
| 6 hour child | 5.36 ± 1.96 | 5.51 ± 1.99 | 6.68 ± 2.63 | 0.0001 a |
| 6 hour parent | 4.85 ± 2.07 | 5.89 ± 2.09 | 8 ± 1.44 | 0.0001 a |
| 24 hour child | 3.49 ± 1.88 | 3.89 ± 2.15 | 4.43 ± 2.06 | 0.16 a |
| 24 hour parent | 3.40 ± 1.95 | 4.29 ± 2.46 | 5.64 ± 1.89 | 0.0001 a |
| 1 week child | 1.15 ± 1.23 | 1.77 ± 1.46 | 2.07 ± 1.92 | 0.02 a |
| 1 week parent | 1.40 ± 1.49 | 2.31 ± 1.79 | 3.07 ± 2.27 | 0.001 a |
| 2 weeks child | 0.17 ± 0.56 | 0.66 ± 1.11 | 0.86 ± 1.00 | 0.004 a |
| 2 weeks parent | 0.21 ± 0.62 | 1.06 ± 1.39 | 1.71 ± 1.60 | 0.0001 a |
One way ANOVA test.
TABLE 5.
Relationships between parental anxiety and postoperative pain scores.
| Postoperative pain scores | Parental axiety (r) | p |
|---|---|---|
| 6 hour child | 0.35 | 0.0001 a |
| 6 hour parent | 0.49 | 0.0001 a |
| 24 hour child | 0.25 | 0.002 a |
| 24 hour parent | 0.40 | 0.0001 a |
| 1 week child | 0.20 | 0.01 a |
| 1 week parent | 0.32 | 0.0001 a |
| 2 weeks child | 0.24 | 0.003 a |
| 2 weeks parent | 0.42 | 0.0001 a |
Pearson correlation analysis.
Complications developed in 1 (2.1%) patient in Group 1, in 22 (31.4%) in Group 2, and in 16 (57.1%) in Group 3 (p = 0.0001). Fever was present in 1 (2.1%) patient in Group 1, in 12 (17.1%) in Group 2, and in 7 (25%) in Group 3 (p = 0.011). Nausea‐vomiting was not seen in any patient in Group 1, but was observed in 2 (2.9%) patients in Group 2, and in 2 (7.1%) in Group 3 (p = 0.18). Bleeding did not occur in any patient in Group 1, but was observed in 3 (4.3%) patients in Group 2, and in 5 (17.9%) in Group 3 (p = 0.004). No patient in Group 1 was re‐admitted to the hospital. Re‐admission and follow‐up were required by 3 (4.3%) patients in Group 2, and 6 (21.4%) in Group 3 (p = 0.001). No patient in any group underwent re‐operation because of bleeding. The parents were questioned about the child's return to school after 2 weeks. This had not been permitted by 17 (36.2%) parents in Group 1, 38 (54.3%) parents in Group 2, and 24 (85.7%) parents in Group 3 (p = 0.0001) (Table 6).
TABLE 6.
Comparisons of the complications of the children.
| Group 1‐mild anxiety (n = 47) | Group 2‐moderate anxiety (n = 70) | Group 3‐severe anxiety (n = 28) | p | |
|---|---|---|---|---|
| Complication (present/absent) | 1 (2.1%)/46 (97.9%) | 22 (31.4%)/48 (68.6%) | 16 (57.1%)/12 (42.9%) | 0.0001 a |
| Fever (present/absent) | 1 (2.1%)/46 (97.9%) | 12 (17.1%)/58 (82.9%) | 7 (25%)/21 (75%) | 0.011 a |
| Nausea‐vomiting (present/absent) | 0 (0%)/47 (100%) | 2 (2.9%)/68 (97.1%) | 2 (7.1%)/26 (92.9%) | 0.18 a |
| Disrupted sleep pattern (present/absent) | 0 (0%)/47 (100%) | 13 (18.6%)/57 (81.4%) | 14 (50%)/14 (50%) | 0.0001 a |
| Bleeding (present/absent) | 0 (0%)/47 (100%) | 3 (4.3%)/67 (95.7%) | 5 (17.9%)/23 (82.1%) | 0.004 a |
| Re‐admission to hospital (yes/no) | 0 (0%)/47 (100%) | 3 (4.3%)/67 (95.7%) | 6 (21.4%)/22 (78.6%) | 0.01 a |
Chi‐square test.
4. Discussion
Surgical anxiety refers to the fear experienced by patients of the interventions to be made to their body, and the potential complications, pain, and loss of control brought about by these interventions [12]. This anxiety in pediatric surgeries is associated with parental characteristics, the child's characteristics, the type and severity of the operation, and the surgical procedure [13]. The anxiety experienced by the parents of children before an operation is recognized as a significant source of preoperative anxiety in children [14].
The results of the current study showed that the pain scores and complication rates of the children of parents with severe anxiety were higher. As parental anxiety increased, so the postoperative pain scores of both the children and the parents increased. The operation of the child is a source of serious anxiety for both the child and parents. Even if this is thought to be a normal reaction, excessive preoperative anxiety can have a harmful effect on the postoperative course. It has been shown that this anxiety leads to negative behaviors postoperatively, a longer stay in hospital, and even behavioral problems [15, 16]. Although the relationship between preoperative anxiety in children and the above‐mentioned negative behaviors has been investigated, there is limited information about the effect of parental anxiety on postoperative pain and the development of complications in children [2, 17]. Psychosocial factors and behavioral factors associated with the child and the parent are important subjects that require evaluation for the postoperative processes of pediatric surgeries to be able to be managed appropriately [2, 4]. Parental pain catastrophizing may mediate the relationship between children's anticipated pain in painful medical procedures and their actual pain experience, and it is a significant predictor of higher postoperative pain levels [18, 19]. A previous study found that a high level of parental preoperative anxiety increased postoperative pain scores and prolonged the use of analgesia in children undergoing tonsillectomy [2]. The anxiety level of the parent plays an important role in the pain experience of the child [4]. Anxiety sensitivity (AS) is defined as fear of the sensations that can be associated with bodily sensations and increases the intensity of somatic complaints [20]. Although AS and pain catastrophizing are defined separately, they have common cognitive dimensions [4]. In the current study results, the pain scores at postoperative 6 and 24 hour, 1 week, and 2 weeks were determined to be statistically significantly higher in Group 3 (except the 24‐h child pain score). Although the 24‐h child pain scores in Group 3 were higher than those of the other groups, the difference was not statistically significant (Type II Error). The high pain scores of the children of parents with high anxiety scores can be attributed to these children having somatised the pain more [20].
When the complications that developed in the pediatric patients of the current study were examined, it was determined that many complications were seen at a higher rate with an increase in anxiety levels. Fever, disrupted sleep pattern, bleeding, and re‐admission to hospital were determined at a statistically significantly higher level in Group 3. Nausea‐vomiting was also seen at a higher rate in Group 3, but did not reach a statistically significant level. The management of postoperative pain is one of the most critical factors in the postoperative recovery process, and parents have an important role in the pain management of the child after an operation. The parent's perspective of pain is extremely important [4, 18]. Tonsillectomy is one of the most painful surgical procedures and has a long recovery period [21, 22]. Therefore, pain management in this recovery period is very important. When pain is not properly managed, the recovery period of a child can be negatively affected. Potentially, oral intake can be reduced, dehydration can develop, and consequently, complications can be seen at a higher rate.
Previous studies have found a higher level of baseline anxiety in mothers with a low education level or who are housewives [17, 23]. It has also been determined in the literature that mothers are more anxious than fathers about anesthesia and operations of their children. However, it has been reported that this anxiety can be reduced with positive interventions to the mothers [15, 24, 25]. Consistent with this information, the current study results showed that the parental anxiety level was higher in Group 3, and the majority of these parents were mothers. The education level of Group 3 was lower, but not at a statistically significant level.
The development of various psychosocial interventions has been recommended to reduce the effect of parental anxiety on the postoperative recovery period of children. In a previous review, it was reported that perioperative parental anxiety was associated with the development of both acute and chronic postoperative pain in children. The review suggested the need for the development of strategies to reduce parental preoperative anxiety levels. In this review, it was stated that providing parents with sufficient information about the surgical procedure and preoperative participation in psychological support programs could lead to positive outcomes for both the child and parents [26]. Preoperative parental education with informative brochures or counseling has been found to significantly decrease the anxiety of parents of children undergoing ear, nose, and throat operations or surgery for congenital heart disease [18]. In the same context, therapies using play‐based interventions such as clown therapy and interventions using music have been shown to reduce preoperative parental anxiety [15]. Although all these strategies have been shown to reduce the preoperative anxiety of parents, it is not known whether or not they lead to a decrease in pain scores and complication rates in children undergoing adenotonsillectomy. Therefore, there is a need for further studies on this subject.
The main limitation of this study was that the anxiety status of the children was not evaluated separately. However, when forming the study sample, children diagnosed with any psychological disease, including anxiety, were excluded. To the best of our knowledge, this study is the largest patient series in the literature that has evaluated the effect of parental anxiety on the postoperative pain of children undergoing adenotonsillectomy. It is also the first prospective study to have evaluated the effect of parental anxiety on complications in these patients.
5. Conclusion
The results of this study demonstrated that postoperative pain and complications were seen at a higher rate in children undergoing adenotonsillectomy whose parents had a high level of anxiety. The majority of the parents with high anxiety levels were mothers. Preoperative psychosocial support given to parents could reduce pain and complications to lower levels. There remains a need for further prospective randomized studies with larger patient series on this subject.
Ethics Statement
The report was approved by the Local Ethics Committee (14.08.2024/AEŞH‐BADEK‐2024‐775) and complied with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.
Conflicts of Interest
The authors declare no conflicts of interest.
Doluoglu S., Gazeloglu A. Z., Kocyigit Y., Vural Camalan B., and Ozlugedik S., “Effects of Parental Anxiety on the Postoperative Pain and Complications of Children Undergoing Adenotonsillectomy,” The Laryngoscope 135, no. 9 (2025): 3422–3429, 10.1002/lary.32217.
Funding: The authors received no specific funding for this work.
Data Availability Statement
Data are available upon reasonable request from the corresponding author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data are available upon reasonable request from the corresponding author.