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BACKGROUND AND OBJECTIVES: The Preschool Obstructive Sleep Apnea Tonsillectomy and Adenoidectomy study is a prospective randomized controlled study of children aged 3 to 5 years. This follow-up evaluated postoperative outcomes 24 months after randomization. METHODS: Baseline, 12-month, and 24-month assessments included intellectual ability, polysomnography, audiology, a pediatric sleep questionnaire, the parent rating scale of the Behavior Assessment System for Children, and the Behavior Rating Inventory of Executive Functioning. RESULTS: In total, 117 (55% male) of 190 children, 61.6% of those initially randomly assigned, attended 24-month follow-up; 62 of 99 were assigned T/A within 2 months (eT/A); and 55 of 91 were assigned to T/A after the 12-month follow-up (T/A12). Intellectual ability, our primary outcome, did not differ according to the timing of T/A. Exploratory analyses revealed changes in both groups after T/A, including fewer children having day sleeps (eT/A from baseline 97% to 11%,T/A12 from 36% at 12 months to 9%), improved symptom scores (eT/A 0.62 to 0.25, T/A12 0.61 to 0.26; P < .001), improved behavior T-scores (eT/A 71.0 to 59.9, T/A12 63.6 to 50.5; P < .001), and improved polysomnography (obstructive apnea- hypopnea index eT/A 1.9 to 0.3 per hour, T/A12 1.3 to 0.3; P < .001). The eT/A group revealed temporary postoperative improvement of Woodcock-Johnson III subscales (sound blending and incomplete word scores) and behavioral withdrawal. CONCLUSIONS: T/A for mild obstructive sleep apnea led to large improvements in sleep and behavior in preschool-aged children, regardless of the timing of surgery. [ABSTRACT FROM AUTHOR]