My 11-month-old has had chronic ear infections for the past nine months. The pediatrician and ENT are recommending tubes. My understanding is that in years past, suppression therapy was recommended, but is not in vogue now. The pediatrician said suppression therapy is not usually effective. Our daughter has taken antibiotics when diagnosed with ear infections, but as soon as she comes off the medication, they reappear. What is your opinion of the effectiveness of these two methods? What are the risks of each? I hate to see my baby go under general anesthesia unless it's absolutely necessary.

A.B.

Tubes are a very effective means for reducing the number and severity of ear infections. Some ear, nose and throat doctors (ENTs) call them ventilation tubes and some call them pressure equalization tubes, or PETs. Both names are fairly accurate. These tubes ventilate (allow air into) the space behind the eardrum, known as the middle ear space. Tubes also allow air pressure to equalize between the outside world and the middle ear.

Some children suffer from a different problem: They have persistent middle ear fluid (effusions). Effusions are uncomfortable and cause poor hearing. The hearing loss from an effusion is very reversible; following the operation, the child usually wakes up with normal (or near-normal) hearing.

"Suppression therapy" is usually referred to as "antibiotic prophylaxis." Following a successful course of antibiotics at a therapeutic dose, the child is placed on a prophylactic dose of antibiotic (the same antibiotic or a different one, typically at one-half to one-third the therapeutic dose) for three to six months. "Prophylaxis" means "prevention." The rationale is this: Let's give your daughter an extended period of time in which she can be free of infections. Hopefully, either (1) she will "outgrow" this problem, or (2) her middle ears will reacquire the normal resistance to infection.

Your impression is correct regarding the effectiveness of tubes and prophylaxis. One can cite successes and failures for both approaches. Here's the scoop:

TUBES:

Pros: The great majority of children will have significantly fewer infections after the tubes are placed. For example, a child who has had six infections in the last six months will typically have only one, or at most two, infections in the six months following the operation. If the tubes are placed for persistent middle ear effusions, the hearing improvement is immediate and dramatic. The operation is simple, so the anesthetic time is very brief (roughly 15 minutes). Serious operative complications are very rare. Finally, most children (about two-thirds) will never need another ear operation.

Cons: Any surgical procedure has risks, and this one is no exception. The risks include bleeding, anesthetic complications, premature tube extrusion (ejection), a persistent eardrum perforation once the tube falls out, persistent drainage from the tube, and tube occlusion (in which the hole in the tube becomes plugged with dried blood, earwax or dried pus). Fortunately, all of these risks are very uncommon.

The tube may cause scarring of the eardrum. Although the first set of ventilation tubes only occasionally causes a significant degree of scarring, each subsequent set (if the operation must be repeated) causes additional scarring. This scarring causes a variable degree of hearing loss.

For children older than your daughter, the tubes can be very inconvenient. Although most children (and infants) with tubes may bathe without precautions, swimming requires special care. Earplugs and an ear "band" (or bathing cap) should be worn to prevent water from entering the middle ear via the tube.

PROPHYLAXIS:

Pros: When it works, it allows the child to avoid an operation, the risk of eardrum scarring and the water-in-the-ears issue. If prophylaxis fails to work, tubes are still a good option.

Cons: Antibiotics are not without risk. Most people are aware of the common problems associated with antibiotics (diarrhea, yeast infection, rash). However, there are some fairly nasty (but rare) risks associated with any antibiotic. Bone marrow suppression (leading to anemia, easy bleeding, immunodeficiency) and Stevens-Johnson syndrome (severe ulceration of the mouth and other mucous membranes) are two examples of rare but life-threatening complications of antibiotic use.

If prophylaxis fails to work, then the child will continue to have recurrent ear infections. Each ear infection is associated with a small (but important) risk of serious complications; some examples are hearing loss, mastoiditis, eardrum perforation, bacterial meningitis and brain abscess. Antibiotics greatly reduce the risk that one of these complications will develop, but some degree of risk is still present.

A final thought: Some parents decide against PETs because they think that by avoiding surgery they are sparing their child from a risky procedure. In reality, each option has risks and benefits. Total avoidance of risk is impossible.