Originally described more than a century ago, vocal fold injection in the awake, unsedated patient has returned to routine clinical use because of improved injectable materials and flexible laryngoscopy optics. The vocal fold may be injected via a number of approaches to remedy conditions of glottic insufficiency including vocal fold paralysis and paresis, atrophy, and scar. Its use in the treatment of treating benign mass lesions is an evolving topic. Trial injections may be performed in cases of uncertain benefit, a use which has revealed the importance of glottic insufficiency in an unexpected variety of complaints. Injection materials are generally well tolerated, although injection into the superficial tissues of the vocal folds is to be avoided. Although laryngeal injection in the awake patient demands some technical expertise and finesse, procedure completion rates are high with low rates of complications, comparable to injection under anesthesia.