BACKGROUND Tracheostomy is a surgical procedure that is done by creating an ostomy in the anterior wall of the trachea to facilitate airway access and ventilation. It is indicated for acute respiratory failure after prolonged intubation, upper airway obstruction, difficult airway, and extensive secretions. Early perioperative complications include bleeding, pneumothorax/pneumomediastinum from a false tract, subcutaneous emphysema, esophageal perforation, and tracheal ring fractures. CASE REPORT We present the case of a 64-year-old woman with a past medical history of hypertension, asthma, alcohol and cocaine abuse, bipolar, and, right breast cancer that was treated by chemotherapy and total mastectomy. She was diagnosed with adductor spasmodic dysphonia of unknown etiology 6 months ago and has been treated with Botulinum toxin injection, with an incomplete resolution. She was admitted to the Respiratory Intensive Care Unit with acute hypoxic respiratory failure associated with stridor secondary to laryngospasm, which was unresponsive to steroids and racemic epinephrine. She underwent an emergent open tracheostomy with a regular nonfenestrated tracheostomy tube. A few hours after surgery, she was weaned from mechanical ventilation to a tracheostomy mask oxygen and had an episode of strong cough followed by extensive neck and facial subcutaneous emphysema. CONCLUSIONS Subcutaneous emphysema is a rare complication but it can be catastrophic, especially if it is associated with pneumothorax and/or pneumomediastinum. Avoiding tight a tracheostomy tube strap and fenestrated tracheostomy tube is one of the measures that can be used to avoid this complication.