My question concerns my five-year-old son. Two years ago, he had a tonsillectomy with adenoidectomy and myringotomy tubes placed for multiple chronic ear infections. He is speech-delayed now due to loss of hearing, which returned to normal after the surgery. Now he is getting ear infections again. How long should I wait before pushing the issue of tubes again? He has come so far, I would hate for him to be set back. At age three he had the speech development of a 14-month-old. Now, after extensive therapy, he is about one year behind.

Jana

While this is undoubtedly a frustrating and worrisome problem for you, the decision-making process is actually quite straightforward. Myringotomy tubes (also known as "ventilation tubes," "pressure-equalization tubes," or "ear tubes"are placed for a handful of reasons:

• Frequent ear infections. The parent and the ear, nose and throat specialist (ENT) must decide together how many is "too many."
  
• Severe or complicated ear infections. Understandably, a BAD ear infection should be considered more serious than a trivial ear infection. For example, even one ear infection complicated by meningitis (infection of the membranes covering the brain and spinal cord) would, in my opinion, warrant tubes.
  
• Persistent middle-ear fluid leading to hearing loss. Once again, the parent and the ENT must decide together "how much hearing loss is too much." If his ENT can document (by appropriate testing) that your son has hearing loss in both ears due to middle-ear fluid, then placement of tubes will almost certainly improve his hearing. But should you wait it out? After all, most middle-ear fluid collections will resolve spontaneously, if given enough time ... leading to the next doctor-mom conversation, "how much time is too much time?" In my opinion, in "second-timers" such as your son, tubes are a reasonable option after three months of persistent middle-ear fluid.
  
• Severe, persistent ear pain that appears to be related to eustachian-tube dysfunction.
  
• Certain changes in the shape or appearance of the eardrum also suggest the need for tubes. "Retraction pockets" can herald the imminent development of cholesteatoma and should be watched very closely, if the decision is made not to place tubes.
  

Thus, the decision "to tube or not to tube" is, inevitably, a judgment call arrived at through consultation between the doctor and the parent.

It is also reasonable to ask whether other alternatives are available. Now, tubes are extraordinarily effective, and I do not want to dissuade you from having the second set of tubes for your son, if this is the right thing to do. But I also believe that people should be aware of their alternatives, even if they are cruddy alternatives. Accordingly, here are some options you may wish to discuss with your son's ENT:

• Aggressive management of allergy (if your son has allergies).
  
• Aggressive use of antibiotics (for example, treatment for three to four weeks instead of the usual seven to 10 days; alternatively, low-dose preventive treatment for three or four months).
  
• Elimination of environmental risk factors. Translation: if your son is exposed to secondhand smoke, see to it that he is NOT.
  
• Treatment with antihistamines, nasal steroid sprays and decongestants. Incidentally, the scientific evidence that any of these drugs reduces the frequency of ear infections (or speeds the clearance of middle-ear fluid) is NONEXISTENT.
  

Other nonsurgical options may exist for your son. The ENT should be very familiar with your son's medical history, the appearance of his eardrums and the severity of his hearing loss. Your son's ENT would certainly know whether there are any other reasonable treatment options.