High-frequency oscillatory ventilation (HFOV) is used extensively in the neonatal population. In adults, it is still considered an alternative mode of ventilation for cases of severe acute respiratory distress syndrome refractory to conventional mechanical ventilation (CMV). Reported complications with HFOV among adults include pneumothorax, pneumomediastinum, and subcutaneous emphysema. Ventilator-associated necrotizing tracheobronchitis (VANTB) is a well-documented complication with HFOV in neonates. In adults, only 11 cases have been reported, 9 patients on high-frequency jet ventilation, and 2 patients on CMV. We report a case of VANTB in an adult on HFOV, discuss potential causes, and offer management options.