Eighty-one patients with long-term tracheostomy tubes (mean duration, 4.9 months) were examined via fiberoptic bronchoscopy prior to decannulation. Obstructive airway lesions were observed in 54 patients (67 percent). All tracheal lesions were anatomically located proximal to the stoma. No cuff lesions were observed. The two most commonly observed lesions were tracheal granuloma (60 percent) and tracheomalacia (29 percent). Less frequently observed lesions were tracheostenosis (14 percent) and vocal cord and laryngeal dysfunction (8 percent). As a result of the high frequency of tracheal abnormalities, especially that for tracheal granuloma which has not been previously reported (to our knowledge), we recommend that all decannulation candidates undergo anatomic examination of the airways.