Laryngotracheal diversion and separation are definitive procedures for the treatment of intractable aspiration. Laryngotracheal separation is the preferred technique because of its simplicity, low morbidity, effectiveness, and applicability to patients with a previous tracheostomy. As we gain additional experience with these procedures, we can better define the decision-making process in the treatment of patients with intractable aspiration. In patients with a tracheostomy, a Passy-Muir valve (Passy-Muir, Irvine, CA) is often effective in preventing aspiration and may avoid the need for further definitive surgery. Most patients undergoing laryngotracheal separation lose little speech function due to an underlying neurologic disease. Many patients are able to resume a regular diet following surgery. Successful vocal rehabilitation using a tracheoesophageal prosthesis has been demonstrated in patients undergoing laryngotracheal separation.