The mediating role of pain in the relationship between perioperative anxiety and postoperative recovery following adenotonsillectomy in children.

BACKGROUND: Adenotonsillectomy is one of the most common pediatric otorhinolaryngological procedures. Although perioperative anxiety and postoperative pain are known to influence recovery, the mechanisms underlying these relationships remain unclear. This study aimed to examine the relationships among perioperative anxiety, postoperative pain, sleep quality, and postoperative recovery, and to determine whether postoperative pain mediates the relationship between perioperative anxiety and postoperative recovery in children undergoing adenotonsillectomy. METHODS: This prospective observational study was conducted in the otorhinolaryngology department of a university hospital between August 2024 and May 2026. A total of 130 children aged 5-12 years undergoing adenotonsillectomy and one parent were included. Perioperative anxiety was assessed using the Perioperative Multidimensional Anxiety Scale for Children. Postoperative pain, sleep quality, and recovery were evaluated on postoperative day 1 and week 1 using the Parents' Postoperative Pain Measure, Sleep Quality Scale, and Postoperative Recovery in Children Scale, respectively. Hierarchical multiple regression and Hayes PROCESS Macro (Model 4) mediation analyses were performed. RESULTS: Postoperative pain decreased significantly, and postoperative recovery improved significantly from postoperative day 1 to week 1 (both p < 0.001). There was no significant change in sleep quality (p = 0.232). Hierarchical regression analysis revealed that postoperative pain was the strongest predictor of postoperative recovery on both postoperative day 1 (β = 0.335, p < 0.001) and week 1 (β = 0.378, p < 0.001). Mediation analyses revealed that, while perioperative anxiety was not directly associated with postoperative recovery, it had a significant indirect effect through increased postoperative pain. Specifically, higher anxiety levels were associated with greater postoperative pain, which in turn was related to poorer recovery outcomes. CONCLUSION: Postoperative pain mediates the relationship between perioperative anxiety and postoperative recovery in children undergoing adenotonsillectomy. Identifying perioperative anxiety early and implementing supportive, non-pharmacological strategies to address it may improve postoperative recovery outcomes. These findings emphasise the importance of addressing psychological factors alongside standard postoperative care.