My three-year-old son has a bad slobbering problem. People have told me it is because of his tonsils and adenoids. I have seen a doctor about it and he says that they are enlarged and he should have them taken out. As a baby he had continuous middle-ear infections and still does. He has broken out from every antibiotic given to him, so they don't help. Should I take him to an ENT and see what he has to say?

N.C.

The size of tonsils and adenoids is not in itself reason to remove them. However, if a child is having health problems due to large tonsils and adenoids, surgery may be necessary.

Most children with big tonsils and adenoids will not drool, but on the other hand, many children who drool do, in fact, have big tonsils and adenoids. Here are some other problems that are related to big tonsils and adenoids:

• Mouth-breathing.
  
• Loud snoring. In some cases, the child will frequently stop breathing for a short time, then gasp for breath. This is known as "obstructive sleep apnea."
  

• Poor feeding, sometimes causing growth delay.
  
• Chronic nasal drainage (due to large adenoids).
  
• Drooling, obstructive sleep apnea, growth delay and chronic nasal drainage: any one of these problems constitutes a good reason for surgery, but only if these problems are clearly due to enlarged tonsils and adenoids and not to some other problem. To determine this, your doctor's diagnostic ability is crucial. A good diagnostician will not immediately assume that your son's drooling is due to large tonsils and adenoids but will consider all other possible explanations.

Let's start with a few words about drooling. We are constantly producing saliva. The reason we don't drool is that we swallow this saliva. Drooling thus suggests the possibilities of an impaired ability to swallow, an impaired ability to retain saliva in the mouth or excessive saliva production.

Excessive saliva production occurs in infants and children with gum inflammation (gingivitis) or dental disease. Infants who are teething tend to drool, but this is obviously not the explanation for drooling in your three-year-old. In an older child, drooling can be related to gingivitis or tooth decay or infection. Excessive saliva production is also a symptom of poisoning from particular chemicals, such as anticholinesterases, which are present in insect poison.

Impaired ability to swallow occurs in children with neuromuscular problems, such as cerebral palsy. Drooling is only one of many problems endured by such children, so the diagnosis is usually not difficult.

Impaired ability to retain saliva in the mouth is usually a result of neurologic problems, but it may also be related to disproportion between the tongue and lower jaw. Tongue enlargement occurs in a few uncommon syndromes. Far more commonly, tongue size is normal, but the lower jaw is not growing in proportion to the tongue and face.

What sort of doctor does your son need to see? Swallowing is a very complex process, and so a multispecialty approach is best when trying to obtain an accurate diagnosis and appropriate treatment. A pediatric dentist is best qualified to assess the health of your son's teeth and gums and to determine whether there is a growth abnormality of the tongue or jaw. An ear, nose and throat doctor (ENT) is best qualified to assess the possibility that enlarged tonsils and adenoids are causing your son's drooling problem. An ENT can also assess the growth of the tongue and lower jaw. Speech pathologists are best qualified to assess the neurologic aspects of swallowing.

Good luck. Please write back to me to let me know the outcome.