Early confi rmation of tracheal injury is crucial while encountering massive subcutaneous emphysema in emergency department to prevent patients from serious morbidity or mortality. Clinicians often underestimate the difficulty of tracheal intubation, especially for inexperienced physician. We highlight that the use of video laryngoscopy-assisted tracheal intubation or ultrasound for diffi cult airway management. An 80-yearold woman presented to emergency department because of diffuse subcutaneous emphysema in her chest and neck after multiple attempts of intubation. Subcutaneous crepitus was palpated in the chest and neck. The chest X-ray showed diffuse subcutaneous emphysema in chest wall and neck. The computed tomography revealed paratracheal air, focal defect at right posterior aspect of lower trachea and subcutaneous emphysema, pneumomediastinum and pneumoretroperitoneum. Bronchoscopy demonstrated the presence of 2 cm in length longitudinal laceration wound above the carina. She refused surgical intervention and was treated conservatively. Most patients with tracheal injury may present with subcutaneous emphysema and respiratory distress. Diagnosis could be made based on the findings of computed tomography and bronchoscopy examination. Early recognition could prompt surgical intervention and empirical antibiotics administration to preclude immediate acute respiratory distress.