A randomized trial evaluated the effectiveness of early adenotonsillectomy versus watchful waiting in children with obstructive sleep apnea (OSA). The study enrolled 464 children aged 5–9 years with OSA without prolonged oxyhemoglobin desaturation. The primary outcome was attention and executive function measured by the Developmental Neuropsychological Assessment (NEPSY), with no significant difference between groups. However, early adenotonsillectomy showed greater improvements in behavioral, quality-of-life, and polysomnographic outcomes, with 79% of children in the surgery group achieving normalized polysomnographic findings compared to 46% in the watchful-waiting group. Surgery also reduced OSA symptoms and improved sleep continuity. The study found no significant cognitive or executive function improvements in the early adenotonsillectomy group compared to watchful waiting, but surgery was associated with better behavioral and sleep outcomes. Subgroup analyses showed similar results across age and obesity groups, though black children had less improvement in some measures. Obese children had greater symptom reduction and improved outcomes after surgery. The study had a large sample size, randomized design, and standardized assessments, but excluded children under 5 and those with prolonged desaturation. Follow-up was limited, and the long-term effects of surgery on cognitive and behavioral outcomes were not fully evaluated. Adenotonsillectomy was associated with a low rate of complications and was considered safe. The results suggest that while early adenotonsillectomy does not significantly improve cognitive function, it may benefit children with OSA by reducing symptoms and improving sleep and behavior. The study supports early surgery for OSA in children, particularly in obese and non-obese populations, but emphasizes the need for careful monitoring. The findings highlight the importance of addressing OSA in children to prevent long-term health issues.A randomized trial evaluated the effectiveness of early adenotonsillectomy versus watchful waiting in children with obstructive sleep apnea (OSA). The study enrolled 464 children aged 5–9 years with OSA without prolonged oxyhemoglobin desaturation. The primary outcome was attention and executive function measured by the Developmental Neuropsychological Assessment (NEPSY), with no significant difference between groups. However, early adenotonsillectomy showed greater improvements in behavioral, quality-of-life, and polysomnographic outcomes, with 79% of children in the surgery group achieving normalized polysomnographic findings compared to 46% in the watchful-waiting group. Surgery also reduced OSA symptoms and improved sleep continuity. The study found no significant cognitive or executive function improvements in the early adenotonsillectomy group compared to watchful waiting, but surgery was associated with better behavioral and sleep outcomes. Subgroup analyses showed similar results across age and obesity groups, though black children had less improvement in some measures. Obese children had greater symptom reduction and improved outcomes after surgery. The study had a large sample size, randomized design, and standardized assessments, but excluded children under 5 and those with prolonged desaturation. Follow-up was limited, and the long-term effects of surgery on cognitive and behavioral outcomes were not fully evaluated. Adenotonsillectomy was associated with a low rate of complications and was considered safe. The results suggest that while early adenotonsillectomy does not significantly improve cognitive function, it may benefit children with OSA by reducing symptoms and improving sleep and behavior. The study supports early surgery for OSA in children, particularly in obese and non-obese populations, but emphasizes the need for careful monitoring. The findings highlight the importance of addressing OSA in children to prevent long-term health issues.