Objective To synthesize evidence of the safety and effectiveness of phonation in patients with fenestrated tracheostomy tubes. Methods PubMed, CINAHL, Scopus, Cochrane, and Web of Science databases were searched. The research question was, “Are fenestrated tracheostomy tubes a safe and effective option to facilitate early phonation in patients undergoing tracheostomy?” Studies of fenestrated tracheostomy tubes were assessed for risk of bias and quality of evidence. Data were abstracted, cross-checked for accuracy, and synthesized. Results Of the 160 studies identified, 13 met inclusion criteria, including 6 clinical studies (104 patients), 6 case reports (13 patients), and 1 nationwide clinician survey. The primary indications for a tracheostomy were chronic ventilator dependence (83%) and airway protection (17%). Indications for fenestrated tracheostomy included inaudible phonation and poor voice intelligibility. Patients with fenestrated tubes achieved robust voice outcomes. Complications included granulation tissue (6 patients [5%]), malpositioning (1 patient [0.9%]), decreased oxygen saturation (3 patients [2.6%]), increased blood pressure (1 patient [0.9%]), increased peak pressures (2 patients [1.7%]), and air leakage (1 patient [0.9%]); subcutaneous emphysema also occurred frequently. Patient-reported symptoms included shortness of breath (4 patients [3.4%]), anxiety (3 patients [2.6%]), and chest discomfort (1 patient [0.9%]). Conclusions Fenestrated devices afford benefits for speech and decannulation but carry risks of granulation, aberrant airflow, and acclimation challenges. Findings highlight the need for continued innovation, education, and quality improvement around the use of fenestrated devices.