Establishing an adequate airway through an end stoma after resection of laryngo–tracheal tumors with proximal tracheal involvement is always a challenge for a surgeon. As primary surgery and surgical salvage provides reasonable survival outcomes for many advanced laryngopharyngeal, tracheal, thyroid and esophageal neoplasms, the concept of establishing anterior mediastinal tracheostoma has come into picture. We describe the indications, feasibility, outcomes and techniques of mediastinal tracheostomy described in literature. Every surgeon dealing with head and neck malignancies should be well aware of the techniques to establish a mediastinal stoma if the scenario requires it.