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A primary bacterial pneumonia was suspected and intravenous antibiotics were employed for two weeks. A nasogastric tube was maintained after this septic episode to provide enteral alimentation due to poor oral intake and intermittent abdominal gaseous distention. The tracheostomy tube was temporarily removed at this presentation in the emergency room to examine the airway through the stoma site. A 5.0 cm tracheoesophageal fistula with the nasogastric tube noted at its base was seen. An endotracheal tube was placed into the trachea beyond the fistula temporarily restored adequate ventilation. A chest x-ray film demonstrated bilateral interstitial infiltrates without subcutaneous emphysema. The abdominal x-ray film demonstrated excessive enteric gas and gastric distention. Pressure necrosis of the closely opposed walls of the cervical trachea and esophagus was aggravated by the long-term nasogastric and tracheostomy tube intubation (Fig 1). A cervical approach to attempt control of this fistula was chosen. An anterolateral cervical incision allowed exposure of the cervical phlegmon. The proximal aspect of the fistulous communication below the cricopharyngeal sphincter and the distal extent of the inflammatory process at the thoracic inlet were then carefully dissected. Figure 1. Fistulous communication between the cervicothoracic esophagus and trachea.