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Objective To assess the effectiveness of adenotonsillectomy in children with mild symptoms of throat infection or adenotonsillar hypertrophy. Design Open, randomized controlled trial. Setting 21 general hospitals and three academic centers in the Netherlands. Participants 300 children aged 2-8 years requiring adenotonsillectomy. Intervention Adenotonsillectomy compared with watchful waiting. Main outcomes measures Episodes of fever, throat infections, upper respiratory tract infections, and health related quality of life. Results During the median follow up period of 22 months, children in the adenotonsillectomy group 2.97 episodes of fever per person year compared with 3.18 in the watchful waiting group (difference -0.21, 95% confidence interval -0.54 to 0.12), 0.56 throat infections per person year compared with 0.77 (-0.21, -0.36 to -0.06), and 5.47 upper respiratory tract infections per person year compared with 6.00 (-0.53,-0.97 to -0.08). No clinically relevant differences were found for health related quality of life. Adenotonsillectormy was more effective in children with a history of three to six throat infections than in those with none to two. 12 children had surgery related complications. Conclusion Adenotonsillectomy in children with mild symptoms of throat infections or adenotonsillar hypertrophy has no major clinical benefits over watchful waiting. [ABSTRACT FROM AUTHOR]