Hypothesis: Injection laryngoplasty is just as good as medialization laryngoplasty (thyroplasty type I) for mild to moderate glottal insufficiency. As the recent increase of options (materials and approaches) in vocal fold injection has occurred, the question of treatment selection between vocal fold injection and medialization laryngoplasty has been appropriately raised in a variety of venues. This subject begs the question: Is vocal fold injection equal, inferior, or better than medialization laryngoplasty? Proper assessment of the etiology, nature, and severity of dysphonia and/or dysphagia caused by glottal insufficiency can lead to a rational decision-making process to determine which patients can be successfully treated with vocal fold injection and which will require medialization laryngoplasty. Each procedure has a unique set of advantages and disadvantages. Understanding these and the key elements of assessment of glottal insufficiency will result in a proper selection of these surgical procedures. In recent years, vocal fold injection, for the treatment of dysphonia secondary to glottic insufficiency, is being performed with increasing frequency. This change has been seen for both operating room– and officebased vocal fold injection owing to enhanced office visualization, new injectionmaterials,anddifferentvocal fold injection techniques. Improved in-office laryngeal visualization with “chip-tip” flexible endoscopes and flexible laryngoscopes with working channels has substantially improved image clarity and the procedurebased functionality for in-office vocal fold injection. A host of new biocompatiblematerials, suchasacellular dermis, hyaluronic acid derivatives, and calcium hydroxylapatite, are currently available for vocal fold injection and can be injected via finegauge needles. These developments enable the otolaryngologist to perform a precise vocal fold injection in the awake, upright, seated patient in an outpatient office setting under local anesthesia. When treating glottic insufficiency, no algorithm or studies exist to determine which patients will benefit most from vocal fold injection or medialization laryngoplasty (thyroplasty) as a definitive treatment for glottic insufficiency. When comparing the 2 procedures, vocal fold injection is not necessarily meant to replace medialization laryngoplasty. The 2 are complementary procedures in the otolaryngologist’s armamentarium when treating patients with glottic insufficiency. Although vocal fold injection has many potential advantages over medialization laryngoplasty, there are certainly limitations as well. The decision to use medialization laryngoplasty or vocal fold injection underscores practicing the “art of medicine” in which the choice of treatment modality is dependent on the nature of the glottic insufficiency, patient factors, patient preferences, and surgeon preferencesbasedonclinicalevidenceand their personal results. Clarifying subtleties of an individual’s glottic insufficiency is important when determining optimal treatment. Assessing the tone of the affected vocal fold(s), vocal fold position, and the size and location of the glottic gap is necessary to adequately address glottic insufficiency. Vocal fold injection is an effective means of treating mild to moderate glottic insufficiency caused by paralysis, paresis, atrophy, scarring,or iatrogenicglotticdefects.This treatment modality is unlikely to adequately correct a large glottic gap from a paralyzed, laterally positioned vocal fold, which may be better treated with medialization laryngoplasty. It is important to note that Clark A. Rosen, MD