The Combitube® is a ventilatory device consisting of a twin lumen tube with proximal and distal inflatable cuffs. The major benefit of the Combitube® is that its design and function allow for ventilation through non-laryngoscope-assisted insertion into either the trachea, or esophagus. As with any invasive procedure, intubation using the Combitube® carries certain risks and potential complications. The majority of complications are relatively minor; however, a rare and serious complication reported primarily in the anesthesiology literature is laceration of the esophagus. This reportedly rare injury is increasingly seen by medical examiners/coroners in the forensic setting.

This paper presents a series of three cases of esophageal laceration and a single case of perforation of the hypopharynx associated with the use of the Combitube®, while also exploring potential mechanisms of injury. In addition, this work demonstrates the vital role the medical examiner/coroner plays in identifying existing or potential problems with current or emerging medical devices.