One hundred sixty-four consecutive tracheotomies are reviewed over the 10-year period 1972-1981. Early in the series acute inflammatory airway obstruction was the major indication for tracheotomy, being 60% of cases in the first 3 years. In the last 3 years this fell to approximately 15%. After 1975 nasotracheal intubation replaced tracheotomy for acute epiglottis. More recently it has become the treatment of choice for acute laryngotracheobronchitis. Tracheotomy prior to reconstructive surgery for major craniofacial abnormalities is becoming more frequent. Acquired subglottic stenosis is not a problem in our hospital despite the use of long-term nasotracheal intubation in premature infants, and no tracheotomies were performed for this indication. There were few major complications. Decannulation difficulties were due to obstruction by stomal granulation tissue or displaced flap of anterior tracheal wall. There was no case of hemorrhage, no posttracheotomy stenosis, and no death was attributable to tracheotomy. These results demonstrate that in a major pediatric hospital tracheotomy is a relatively safe and effective procedure with minimal morbidity.