The cohort study developed by Moshed Abdel-Aziz et al, evaluated the feasibility of tonsillectomy in combination with Furlow palatoplasty in a small sample of patients with submucous cleft palate. Their main hypothesis is that the proposed intervention may prevent postoperative obstructive sleep apnea after primary palatoplasty.My concern regarding the methodology and results of this study are discussed as follows. The study includes a small sample of patients with submucous cleft palate characterized by small adenoids and large tonsils followed during short postoperative period of time (3 mo).Adenoid hypertrophy is commonly observed in children with tonsillar hypertrophy unlike the characteristics observed in the study group and it would be good to consider how frequent this form of presentation is. The use of a small number of patients in this study represents a methodological shortcoming and limits the possibility of generalizing the results of the study as it is not representative of the population. On the other hand, postoperative edema and healing process can take more than 3 months to resolve masking the operative outcomes. Some speech parameters as nasalance may be affected by these factors are require longer time of follow-up to be evaluated.Another important limitation is the instrument used for obstructive sleep apnea evaluation (the Epworth sleepiness scale). The subjective nature of this parent-reported scale (ranged from "would never doze" to "high chance of dozing") limits the ability to objectively measure the variable. Observational studies are limited to demonstrate causal relation between the intervention and the outcome and several factors may account for potential variability in outcomes and some confounding variables are present. Important factors may have a role as confounding variables in this study as follows: anatomical variability of the upper airway, weight, age, and gender. Therefore, strategies for the control of confounding variables or the development of experimental studies are necessary. Finally, associated complications should be always well considered in any extended surgery. Hu et al 5 in their publication suggested an increased rate of bleeding and scarring after combined procedure and recommend a separate stage. Early postoperative edema and airway obstruction were also reported in association with combined procedures by different authors. 5,6 This report is an interesting preliminary study presenting an experience combining primary cleft palate repair and tonsillectomy however further researches are necessary to improve observed limitations and obtain valid conclusions regarding this proposal.