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In the USA in 1996 about 280 000 children under the age of 3 years had tympanostomy tubes inserted but there is still debate about the effects of these procedures. Two papers in the New England Journal of Medicine have addressed the timing of tube insertion and the effect of removing the adenoids at the same time. In Pittsburgh (Jack L Paradise and colleagues. New England Journal of Medicine2001;344:1179–87) 6350 babies were studied from the age of 2–61 days. They had at least monthly pneumatic otoscopy and tympanometry up to the age of 3 years. Four hundred and twenty nine children developed persistent (90 days if bilateral, 135 days if unilateral) middle ear effusion and were randomised to either early (as soon as possible) tympanostomy tube insertion or delayed insertion (dependent on persistence of effusion up to 9 months later). By the age of 3 years the rate of tympanostomy tube insertion was 82% (early group) v 34% (delayed group) but there were no significant differences between the two groups on tests of speech, language, cognition, and psychosocial development. These authors conclude, from these and other data, that tympanostomy tube insertion in children of this age group and with middle ear effusions of this duration produces no evident benefit by the age of 3 years (though it is possible that benefit could become apparent on testing the children when they are older). Children with more severe hearing loss or more severe ear disease might benefit from early tympanostomy. In Toronto (Peter C Coyte and colleagues. Ibid: 1188–95) a retrospective study included over 37 000 children who had tympanostomy tubes inserted between 1995 and 1997. They found that children who had had concomitant adenoidectomy (or adenotonsillectomy) were about half as likely to need reinsertion of tympanostomy tubes or to need readmission for “conditions related to otitis media”. Adenoidectomy most benefited children aged 3 years or over. An editorial (Ibid: 1241–2) calls for longer term follow up of the children in the first of these studies and points to difficulties in assessing the clinical implications of the second. When should tympanostomy tubes be inserted? What are the benefits to be expected? What harm might it cause? Should adenoidectomy be performed at the same time? The debate will continue.