Chronic recurrent aspiration can be secondary to numerous pathologic processes, with potential for disastrous sequelae if not diagnosed and aggressively treated. An understanding of the physiology of the swallow can aid in the diagnosis and potential treatment of the aspirating patient. Most aspirating patients can be managed with conservative measures such as diet modification and compensatory techniques. Various innovative surgical procedures have been developed to provide an adjunctive role or definitive treatment in those with a more severe functional deficit.