Background: In patients with severe traumatic brain injury, the goal of this study is to determine whether or not early tracheostomy on day 5 lowers mechanical ventilation time, intensive care unit (ICU) stay, incidence of pneumonia, and death compared to extended intubation. Our study aimed to determine the effects of early tracheostomy on mechanical ventilation time, intensive care unit (ICU) stay, and nosocomial pneumonia. Patients and methods: All patients who satisfied the following selection criteria were prospectively included in the study: Patients with isolated traumatic brain injury with scores of 8 or below on the first and fifth days of the Glasgow Coma Scale were randomly assigned to one of two groups: Total time of mechanical ventilation, ICU duration of stay, incidence of pneumonia, days of mechanical ventilation after nosocomial pneumonia, and mortality were compared between the early tracheostomy (T group, n = 400) and extended endotracheal (I group, n = 400) groups. Results: ICU length of stay was 17.13 (SD 1.93) days in early tracheostomy versus 48.94 (SD 6.08) in the prolonged intubation group, in terms of a p-value that is highly significant (P<0.001). Also, mortality was statistically highly significant in comparison between both groups with only three patients in the early tracheostomy group versus thirty eight patients in the prolonged intubation group. Conclusion: Early tracheostomy in severe traumatic brain injury carries a great beneficial outcome regarding total number of days requiring mechanical ventilation and post-nosocomial pneumonia days requiring mechanical ventilation, incidence of pneumonia, complications either clinical or endoscopic and mortality when compared to prolonged intubation patients.