A 20 month-old female with a known tracheal bronchus and recurrent episodes of aspiration pneumonia presented to the pediatric otolaryngologists for evaluation of a potential tracheal cleft. This child already underwent an extensive workup at a referring hospital for esophageal pathology and was found to be negative. A laryngoscopy was performed under anesthesia and no tracheal cleft was appreciated. However, air was noted to expel from the esophagus during large volume breaths were delivered. Pediatric surgery was consulted to evaluate for 'H' type tracheoesophageal fistula. A bronchoscopy noted a defect 1.5 cm above the carina. Esophagoscopy revealed a likely defect but a guidewire could not successfully be passed so methylene blue was introduced through the endotracheal tube and was visualized leaking into the esophagus under direct vision. Esophagoscopy and CT evaluation suggested an 'H' type fistula well below the second thoracic vertebrate, indicating a right thoracic approach. Video assisted thoroscopy was attempted but the lack of adequate single lung ventilation as a result of the tracheal bronchus made that approach difficult so an posterolateral thoracotomy was performed. At operation, the fistula was ligated but the esophagus continued to inflate with large volume ventilated breaths indicating a second fistulous connection. Further cephalad dissection identified the fistula and the defect was ligated with subsequent resolution of air passage into the esophagus from the trachea. The patient did well post operatively and has had complete resolution of symptoms and has been free of aspiration pneumonia.