CASE PRESENTATION: We present the case of a 31 year old adult who initially presented with fever and hemoptysis and only upon further questioning, reported a past history of congenital H-type TEF, with dysphagia, regurgitation and recurrent bouts of pneumonia. Due to lack of medical coverage in his native country, he was never evaluated for possible repair. He was working as a landscaper with no apparent limitations except occasional symptoms as mentioned before. Physical exam should clubbing with absent breath sounds on the left side. Diagnostic work up including upper endoscopic, esophageal manometry, bronchoscopy and computed tomography of the chest and abdomen was done to determine its anatomy. Patient’s left lung almost completely destroyed from chronic aspiration. He underwent TEF excision and repair via a right postero-lateral thoracotomy using intercostal muscle to buttress the repair. The fistula was about 2 by 2 mm and abut 24 cm from the incisors. Intra-operatively, he would not tolerated single left lung ventilation and surgery was performed with low tidal volumes of the right lung. Post-operative course uneventful with patient tolerating solid food and no aspiration on evaluation by the speech and swallow therapist. At 12 month follow up, patient denied any recurrence of symptoms and clubbing had improved.