Aim: Acquired tracheooesophageal fistulas (TOF) are rare. Whilst it is a known complication in button battery ingestion, there are only few case reports describing TOF caused by other airway foreign bodies such as plastic (1, 2). We present a paediatric case of an acquired TOF from a plastic airway foreign body and highlight the challenges in diagnosis and treatment. Method: A retrospective review of the patient records and relevant literature search was performed. Results: A 9-year-old boy had previously presented to hospital in 2019 (then aged 3) for a 6-month history of recurrent wet cough and intermittent stridor. LBO and flexible bronchoscopy revealed a plastic foreign body in the trachea lodged in an AP axis. Anterior mucosal laceration, oedema, and mild luminal narrowing were noted at the time without a fistula. He was lost to follow up until 2025, presenting again with recurrent purulent sputum for “months”. A CT chest showed a 2mm fistula gap, which was later visualised on an LBO and gastroscopy on the left lateral edge of the posterior tracheal wall. He underwent a repair with Bugbee diathermy and Tisseel, with a repeat diathermy and a suture repair a month later. Further relook 2 months post op confirmed a repaired TOF with no leak of methylene blue dye. Conclusion: This case highlights the diagnostic dilemma and challenges in treating a rare incidence of TOF from an airway foreign body. It underscores the need to maintain a high index of suspicion for airway foreign bodies in the paediatric population to avoid long term complications. Reference 1.Ruangnapa K, Anuntaseree W, Saelim K, Prasertsan P. Acquired tracheo-oesophageal fistula in a child with unrecognised tracheal foreign body. BMJ Case Reports. 2021;14(4):e240947. 2.Chen C, Dai D, Guo Y, Sun C, Li Q. A Peculiar Tracheoesophageal Fistula Caused by a Plastic Foreign Body. Case Reports in Otolaryngology. 2025;2025(1):3983529.