In this level 4 study, Ettinger et al reported that the incidence of obstructive sleep apnea (OSA), as diagnosed by prescription of continuous positive airway pressure (CPAP) by pediatric pulmonologists, was 22% after dynamic sphincter pharygoplasty when it was used as the treatment for all patients presenting with velopharyngeal insufficiency (VPI) for a 13-year period. Three surgeons treated 146 patients. No information is given as to speech results, other complications of surgery, further treatment, and overall long-term results. The surgical technique is not described directly or by reference. The diagnosis of OSA by nonsurgeons, using the need for CPAP as the criterion, increases the objectivity of the assessment of surgical results. Furthermore, all patients with VPI were treated with the same operation, further increasing the validity of the assessment, because the indications for surgery could not have been a source of bias. The most frequent complication of sphincter pharyngoplasty (SP) for VPI is persisting VPI, even in the absence of flap dehiscence. Postoperative airway obstruction of variable severity has been reported after sphincter pharyngoplasty, in some instances requiring CPAP. Although frank OSA has also been reported, it has not generally been felt to be a common complication of this operation, particularly in comparison with its frequency after pharyngeal flaps. The Bdynamic[ nature of the sphincter owing to its reliance on contained functional muscle is assumed to produce a larger resting airway aperture. The authors report a higher incidence of OSA in patients who had previously undergone tonsillectomy and/or adenoidectomy (RR, 2.4), confirming a previous report that speculated that the mechanism may be narrowing of the airway due to tonsillectomy’s causing flap inset under greater tension. An alternative explanation is that adenoidectomy allows a higher insertion site on the posterior pharyngeal wall, closer to the area of palatal contact, where it is both more likely to be effective and more likely to cause airway obstruction. Regardless of the mechanism, greater surgical airway narrowing, as implied by the current authors and others, should in theory increase both velopharyngeal adequacy and pari passu airway obstruction/OSA, so SP, and indeed any operation to decrease nasal air escape, is a double-edged sword. But common sense is not the same as data. As compelling as this supposition is, the published data on speech results and airway dysfunction after SP fail to show a correlation between frequency of normal speech and incidence of respiratory symptoms or OSA. A formal meta-analysis would be of value. In any event the challenge for surgeons is to find the sweet spot of sufficient narrowing for normal nasal resonance but below the threshold of obstruction, although this may not be generally possible. This is a large well-powered study, and the authors do us a favor by identifying the importance of postoperative respiratory monitoring in patients undergoing SP and of having a low threshold for considering the use of CPAP.