Current practice in injection augmentation of the vocal folds: Indications, treatment principles, techniques, and complications

Lucian Sulica, Clark A. Rosen, Gregory N. Postma, Blake Simpson, Milan Amin, Mark Courey, Albert Merati

Research output: Contribution to journalArticlepeer-review

160 Scopus citations


Objectives/Hypothesis: To identify contemporary indications, treatment principles, technique, injection materials, complications, and success rates of vocal fold injection augmentation. Study Design: Multi-institutional retrospective review. Methods: Records of patients undergoing injection augmentation at seven university medical centers from July 2007 through June 2008 were reviewed for information regarding diagnosis, unilateral or bilateral injection, route of injection, anesthesia, treatment site (office or operating room), material used, reason for technique selected, and technical success. Results: In 12 months, 460 injections were performed, 236 (51%) in awake, unsedated patients, and 224 (49%) under general anesthesia. Indications included vocal fold paralysis (248; 54%), paresis (97; 21%), atrophy (68; 15%) and scar (47; 10%). Scar was more likely to be treated in the operating room (P = .000052). In awake patients, 112 (47%) injections were performed by transcricothyroid approach, 55 (23%) by peroral approach, 49 (21%) by transthyrohyoid membrane approach, and 20 (8%) by transthyroid cartilage approach. Neither technical success rate (99% vs. 97%) nor complication rate (3% vs. 2%) differed between awake and asleep techniques. The most common materials in the clinic setting were methylcellulose (35%), bovine collagen (28%), and calcium hydroxylapatite (26%); in the operating room these were calcium hydroxylapatite (36%) and methylcellulose (35%). Calcium hydroxylapatite was more likely to be used under general anesthesia (P = .019). Five-year data show that the use of injection in the awake patient rose from 11% to 43% from 2003 to 2008. Conclusions: Injection augmentation remains a safe, effective, and clinically practical treatment with a high rate of success, whether performed in the awake or asleep patient. The rapid adoption of awake injection over the past 5 years speaks to its clinical utility. Complication rates are low and equivalent to those under general anesthesia. Otolaryngologists continue to use a variety of techniques and materials to treat a range of conditions of glottic insufficiency.

Original languageEnglish (US)
Pages (from-to)319-325
Number of pages7
Issue number2
StatePublished - Feb 2010


  • Focal fold atrophy
  • Glottic insufficiency
  • Hoarseness
  • Injection augmentation
  • Laryngeal paralysis
  • Presbyphonia
  • Sulcus
  • Vocal cord
  • Vocal cord paralysis
  • Vocal fold
  • Vocal fold injection
  • Vocal fold paralysis
  • Vocal fold paresis
  • Vocal fold scar

ASJC Scopus subject areas

  • Otorhinolaryngology


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