BACKGROUND: Bronchoscopic subcutaneous dilatational tracheostomy is fast becoming the method of choice for securing an airway in chronic ventilated patients in an intensive care setting. Many studies have demonstrated that it is a cost-effective and safe procedure in experienced hands. Complications appear to be equivalent to those encountered in open tracheostomy. Subcutaneous emphysema following tracheostomy is a rare occurrence. Only 3 cases have been described following percutaneous dilatational tracheostomy. Management can be quite complex. MATERIAL AND METHODS: Retrospective review with case report of a patient with massive subcutaneous emphysema following percutaneous tracheostomy. CONCLUSION: Massive subcutaneous emphysema following percutaneous tracheostomy is a major complication that is rarely encountered. When due to a posterior tracheal wall tear, management consists of bypassing the laceration and allowing it to heal secondarily.