A postoperative chest radiograph has traditionally been obtained after tracheotomies to evaluate for the presence of a pneumothorax and to assess tube position. Several recent studies in adults have questioned the usefulness of routine postoperative chest radiography in uncomplicated cases, but the role of post-operative chest radiography in pediatric patients has not been previously reviewed. We performed this study to examine the clinical utility of post-tracheotomy chest radiography in pediatric patients and determine if this routine practice impacts patient management enough to merit continued usage. A retrospective review was performed of 200 consecutive pediatric patients who underwent tracheotomies by the otolaryngology service in a tertiary care pediatric hospital from January 1994 to June 1999. All patients received postoperative chest radiographs. Five of 200 patients had a new postoperative radiographic finding, with three requiring interventions. Two patients required chest tube placement for pneumothorax, and one patient required tracheostomy tube change for repositioning. Fifty-one patients, including both pneumothoraces, exhibited clinical signs of pneumothorax (decreased breath sounds or oxygen saturation) in the immediate postoperative period. Chest X-ray ruled out a pneumothorax in the remaining 49 patients. The majority of these 51 patients were less than 2 years old (94%, P=0.002) or weighed less than 17 kg (89%, P=0.004). Postoperative chest X-rays yielded clinically relevant information in 168 patients that fell into one or more of four high risk categories: age less than 2, weight less than 17 kg, emergent procedures, or concomitant central line placement. Avoiding chest X-rays in the remaining 32 patients would have resulted in potential savings of $5000, which does not reflect the actuarial cost of a missed complication. Since the majority of our patients (84%) fell into a high-risk category, we feel it would be prudent to continue obtaining postoperative chest radiographs following all pediatric tracheotomies.