Adequate laryngeal exposure is critical for accurate injectate delivery.

The delivery of the injectate should be thought of in three-dimensional fashion, paying careful attention to the final total contour of the vocal fold.

Augmentation injection laryngoplasty should be performed to medialize the posterior and mid-portion of the musculomembranous vocal fold. Overinjection anteriorly causes a “pressed” voice, which will not relent until resorption of the injectate.

There is no real-time phonatory feedback or mucosal wave evaluation to help with assessing the appropriate injectate volume. If the decision is made to perform the procedure with the patient intubated instead of under jet ventilation, the endotracheal tube may alter the anatomy of the vocal folds and affect judgments regarding the appropriate injectate volume.

If the endotracheal tube cuff is not completely deflated prior to removal, then there is a risk of lateralizing the injectate and compromising results.

If the procedure is performed with a telescope, it is helpful to place the telescope and injection needles each as laterally as possible opposite one another in the proximal aperture of the laryngoscope so they do not cross and impede free movement of their distal ends.

A telescope can assist with improved visualization for optimal three-dimensional delivery of the injectate.

Superficial placement of injectate is to be avoided, as the vibratory characteristics of the native lamina propria will be severely impaired, leading to worsening of voice. If superficial placement is recognized, the injectate should be carefully expressed out and suctioned.

Any additional injectate sitting on the vocal fold(s) after needle removal should be suctioned free to prevent reactive granulation tissue.