Frequently patients require a tracheostomy tube over a prolonged period of time. A number of complications have been reported with the chronic use of tracheostomy tubes including granulation tissue formation, subglottic stenosis, and tracheomalacia. Reports of a tracheostomy tube fracture are rare. Many of these tubes were made of metal such as silver, zinc, and copper.‘.’ It was thought that corrosion of the metal predisposed the tubes to fracture.l With the advent of synthetic tracheostomy tubes in the 196Os, it was hoped that these tubes would be free of the problem of fracture. However, the first report of a synthetic tube fracture was documented in 197X3 Thereafter, several other reports have described synthetic tracheostomy tube fracture. Most of these fractures occurred at the neck plate site. In this article the first case of a fracture in a synthetic fenestrated tracheostomy tube is reported and the literature is reviewed. This case may suggest that the fenestration in the tube may be a weak point and that fracture at that site may occur, particularly after prolonged wear. The patient was subsequently lost to follow-up until his visit to the ear, nose, and throat clinic 4 years later. The patient had not changed his tube during this time period. The patient presented with a foul smell from the tracheostomy tube and a mass under his tube. He had no shortness of breath and no hemoptysis. The patient had a no. 8 fenestrated Shiley tracheostomy tube with a nonfunctional cuff. There was a large amount of peristomal granulation tissue which partially pushed out the tracheostomy neck plate. The patient was brought to the operating room for tracheostomy tube change and excision of peristomal granulation tissue. Under local anesthesia, the tracheostomy tube was inspected. It was noticed that two fractures, approximately 1 to 2 cm in length, were present at the site of the fenestration (Fig 1). The granulation tissue had grown through the fenestration preventing removal of the tube. Excision of the granulation tissue was performed with electrocautery. The tracheostomy tube and fracture site were both grasped and removed with a clamp. A new no. 8 cuffless nonfenestrated Shiley tracheostomy tube was inserted. The patient was discharged with two sets of tracheostomy tubes. He is closely followed up in clinic for tracheostomy tube changes.