The mainstay of treatment for obstructive sleep apnea (OSA) has been tracheotomy until the introduction of continuous positive airway pressure (CPAP). At present, while tracheotomy remains as last resort, it is well documented that it improves survival rates. In patients who cannot tolerate CPAP, fail upper airway surgery and weight loss, it can be life saving. Still, tracheotomy is not a procedure without complications; and with the added medical complexity of the OSA patient, the care of these patients require a team approach and diligent patient education. Tracheotomy should remain in the armamentarium of the sleep apnea surgeon as a possible treatment option with significant benefits.