Tracheostomy is an operation with a long history and many potential complications. Two case reports of acute posterior tracheal wall laceration, a rare complication, are presented. Although previously described as being secondary to inadvertent knife contact with the posterior tracheal wall, both of these cases are thought to be due to insertion of the tube with excessive force against tissue made friable by previous radiation. The diagnosis should be suspected if poor ventilation follows insertion of an endotracheal or tracheal tube. The offending tube should be removed and an oral endotracheal tube inserted. After treatment of any accompanying pneumothorax, the site should be evaluated under direct vision as the endotracheal tube is withdrawn proximal to the tracheotomy. If a tear is found, esophagoscopy is performed to insure the integrity of the esophagus. Repair of the tracheal wall is done with a single layer closure through the tracheotomy alternating suturing with ventilation. A generous tracheotomy, soft tubes and care in insertion of tubes into the trachea are suggested preventive measures.