We report two cases in which tracheal puncture (diagnosed by puncture of the orotracheal tube cuff) followed internal jugular vein cannulation by the posterior approach. This complication is only likely to occur when using posterior approach and it may be followed by potentially dangerous subcutaneous emphysema, pneumomediastinum or air trapping between the chest wall and the pleura. This has led us to believe that the posterior approach should be substituted by the alternative central or anterior approach whenever it is possible.