Background <p>Preoperative anxiety and postoperative discomfort are critical issues in pediatric surgical management, especially in children undergoing tonsillectomy/ adenoidectomy. Virtual Reality (VR) is an immersive, non-pharmacological approach that may alleviate anxiety and improve procedural tolerance.</p> Aim <p>The aim of this study was to assess the efficacy of a 360-degree educational virtual reality movie in alleviating preoperative anxiety and postoperative discomfort in children aged 6 to 12&#xa0;years undergoing tonsillectomy/adenoidectomy.</p> Methods <p>A single-blind, randomized controlled trial was performed with 92 pediatric patients allocated to either an experimental group (<i>n</i> = 46), who viewed a 360° VR educational video, or a control group (<i>n</i> = 46) that got conventional preoperative care. The Children’s Fear Scale and Wong-Baker Faces Pain Rating Scale were employed to evaluate preoperative anxiety and postoperative discomfort, respectively. The Wilcoxon Signed Rank test and the Mann–Whitney U test were employed for data analysis.</p> Results <p>Participants in the VR group demonstrated markedly reduced fear scores following the intervention (Median (Q3-Q1) = 2 (3–1)) in contrast to pre-intervention levels (Median (Q3-Q1) = 3 (4–2), <i>p</i> &lt; 0.001), as well as when compared to the control group (Median (Q3-Q1) = 3 (4–2), <i>p</i> &lt; 0.001). Postoperative pain levels were considerably reduced in the VR group (Median (Q3-Q1) = 6 (7–5)) compared to the control group (median = 7 (8–6), <i>p</i> &lt; 0.001).</p> Conclusion <p>A 360° educational movie in virtual reality was associated with significantly lower preoperative fear and postoperative pain compared with standard care in children undergoing tonsillectomy/adenoidectomy. The findings suggest that VR may serve as a valuable adjunct in pediatric preoperative preparation; nevertheless, further large-scale and multi-center studies are necessary to corroborate these results.</p> Trial registration <p>Retrospectively registered. approved by TCTR Committee on 13 May 2024. The TCTR identification number is <a href="https://www.thaiclinicaltrials.org/show/TCTR20240513003">TCTR20240513003</a>.</p>