Association between obstructive sleep-disordered breathing severity and pain trajectories after adenotonsillectomy in children
A prospective cohort study.
British Journal of Anaesthesia
Submitted April 2026 by Dr Timothy Marmion
Overview
This prospective cohort study examined whether the severity of obstructive sleep-disordered breathing (oSDB) influences postoperative pain following adenotonsillectomy in children aged 2–12 years. Given the pro-inflammatory state associated with oSDB and its potential interaction with nociception and opioid sensitivity, the authors hypothesised that children with more severe symptoms would experience greater postoperative pain and analgesic requirements.
Methods
Children undergoing adenotonsillectomy had preoperative assessment of oSDB severity using the modified STBUR (mSTBUR) questionnaire. Postoperative pain was measured using the Parents’ Postoperative Pain Measure (PPPM), recorded in a diary, twice daily for up to 14 days, with analysis focused on the first 10 postoperative days.
Pain trajectories were identified using group-based trajectory modelling, incorporating both complete and imputed datasets due to a substantial proportion of missing pain scores. Analgesic use and unscheduled hospital revisits were also recorded.
Results
Three distinct pain trajectories were identified:
- Mild/brief pain (Trajectory 1) (44%)
- Moderate pain (Trajectory 2) (37%)
- Severe/prolonged pain (Trajectory 3) (19%)
Pain scores diverged early, with trajectory largely apparent from postoperative day 1. Children in the severe trajectory continued to experience clinically significant pain (PPPM >6) into the second postoperative week.
Higher preoperative mSTBUR scores were associated with increased likelihood of belonging to Trajectory 3 versus Trajectory 1 (OR, 0.52; 95% CI, 0.27—0.97; P=0.0395). This association was stronger in younger children.
Children in the moderate and severe trajectories required more analgesia and had significantly higher rates of unscheduled revisits, approximately 4-fold and 10-fold increases respectively compared with the mild group.
Discussion
This study demonstrates that post-adenotonsillectomy pain is not a uniform experience, but can be modelled to follow distinct and predictable trajectories. The association between oSDB severity and worse pain outcomes is clinically plausible, given the inflammatory and hypoxaemia-related mechanisms described in sleep-disordered breathing.
One of the most useful findings is the early separation of pain trajectories, suggesting that postoperative day 1 pain scores may help identify children at risk of prolonged recovery. This creates an opportunity for early escalation of analgesic strategies and closer follow-up.
There are several important limitations. Analgesic regimens were not standardised, introducing variability that may confound interpretation of pain scores and the rate of unscheduled revisits. Completed diaries were returned from 124 participants, leaving 121 (49%) of diaries requiring imputation for missing data. Pain assessment relied on parent-reported measures, which may be subjective and influenced by expectations or education.
Despite these limitations, the findings are relevant to everyday practice, particularly in highlighting a subgroup of younger children with severe oSDB who may be at increased risk of poor postoperative outcomes.
Strengths
- Prospective design with longitudinal pain assessment
- Use of trajectory modelling to capture clinically meaningful patterns
- Inclusion of patient-centred outcomes such as home pain and hospital revisits
Shortcomings
- High proportion of missing data requiring imputation
- Non-standardised analgesic regimens
- Single-centre design limits generalisability
- Reliance on caregiver-reported pain scores
Take Home Messages
- Post-adenotonsillectomy pain in children follows three distinct trajectories, with nearly 20% experiencing severe and prolonged pain.
- Greater oSDB severity (higher mSTBUR scores) is associated with worse pain outcomes and increased healthcare utilisation.
- Early postoperative pain (day 1) may help identify children at risk and guide more proactive, individualised analgesic strategies.
