Major late complications, following radiotherapy of head and neck carcinomas, such as laryngeal oedema, perichondritis and chondronecrosis usually occur between three and 12 months after treatment. However, the present case displayed necrosis of the laryngo-tracheal cartilage and ulceration of anterior neck skin with a tracheal fistula 44 years after irradiation. The reasons for the long interval between irradiation and late complications may be explained by long-standing hypovascularity and/or infection of the irradiated area. Histological study revealed chondronecrosis without inflammatory cells in the laryngo-tracheal cartilage and bacterial colonization of subcutaneous tissue. Necrotic tissue was removed and tracheostomy was performed. The fistula was almost completely closed using a delto-pectoral cutaneous flap and the clinical course of patient has been good. This paper demonstrates the possibility of laryngo-tracheal necrosis in cases that had received radiation as long ago as 44 years.