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A case of extensive pneumomediastinum and subcutaneous emphysema is presented, after endotracheal intubation with a metallic endotracheal tube during laser epiglottectomy. A 69 year old woman had a laser tube intubation-related tracheal injury. The patient was managed with intubation and chest tube insertion as well as antibiotic treatment. The patient made a full and uncomplicated recovery and was discharged 10 days after the original injury. Aggressive surgical repair for such injuries is not always mandatory. In the absence of infectious complications, a conservative approach is an option for lesions 3 cm above the carina where it is possible to inflate a cuff. Urgent chest CT scanning subsequently can confirm extensive mediastinal and subcutaneous emphysema and probable tracheal laceration. The use of a laser tube during laser laryngeal microsurgery requires meticulous care. Korean J Otorhinolaryngol-Head Neck Surg 2010;53:47-9