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Medical Procedures

The physicians and surgeons of Head & Neck Surgical Associates are medical doctors, as well as dentists. After medical school they continued their specialized training in various residency programs in Otolaryngology/Head and Neck Surgery, Oral and Maxillofacial Surgery and Plastic and Reconstructive Surgery.

HNSA’s surgeons have devoted their professional energies towards the management of a variety of complex problems affecting the head, neck and cranio-maxillofacial skeleton. The practice offers a number of medical procedures including diagnosis of cancers affecting the head and neck, orthognathic surgery (corrective jaw surgery), temporomandibular joint (TMJ) surgery, facial trauma surgery, cosmetic surgery and cleft/craniofacial surgery.

Our medical staff has spent their entire careers focusing upon the head and neck, thus you can be assured that you will receive the most comprehensive and specialized treatment available today. We look forward to meeting you and creating a personal treatment plan for you.

• Cleft Palate and Craniofacial Surgery
• Facial Trauma Surgery
• Head and Neck Oncological (Cancer) Surgery
• Orthognathic (Corrective Jaw) Surgery
• Reconstructive Surgery
• Snoring and Sleep Apnea Surgery
• Tempormandibular Joint (TMJ) Disorders and Surgery

Cleft Palate and Craniofacial Surgery

As both physicians and dentists, the surgeons at Head & Neck Surgical Associates are uniquely qualified to manage all phases of surgical care for patients born with cleft lip or other craniofacial abnormalities. Children with these complex congenital deformities require a team approach to their management including surgery, speech pathology, orthodontics, pediatric dentistry, genetics, occupational therapy, and developmental pediatrics. Recognizing the need for such a group, Dr. Eric Dierks and Dr. Bryce Potter founded the Emanuel Cleft Lip/Palate Team in 1991.

Our cleft and craniomaxillofacial surgeons are both physicians and dentists. We feel the cleft surgeon must have degrees in both medicine and dentistry to render the most effective and comprehensive care. Our surgeons, as well as our medical staff, regard “clefting” as simply a variation of nature and do not assign the terms “normal” vs. “abnormal” to children with cleft lip/palate needs. Early parental education and support is a critical element of the overall successful management of a cleft child. Parents who have recently discovered by ultrasound examination that they have a child with a cleft make an understandable and important adjustment to this finding. Our doctors and staff look forward to interacting with pregnant parents of a cleft child and help them through the process of learning about clefting and related treatments well before birth. Therefore, parents can be fully informed and prepared prior to childbirth, knowing that their newborn will be properly cared for by highly skilled and experienced surgeons.

In conjunction with members of the Craniofacial Center at Legacy Emanuel Hospital and Health Center, surgeons at HNSA treat congenital and acquired deformities of the craniofacial skeleton and soft tissues. These disorders include craniosynostosis, Apert’s Syndrome, orbital hypertelorism, temporomandibular joint (TMJ) disorders, Crouzon’s Syndrome, Treacher-Collins Syndrome, facial clefts, dental-facial deformities and facial tumors. The surgical team examines patients and discusses treatment plans weekly, allowing patients to see most or all related specialists in a single visit.

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Treatment Protocol: Cleft Lip and Palate

Month One

Clinic visit for general pediatric evaluation with emphasis on feeding difficulties, hearing problems, genetic counseling, dental evaluation and possible construction of dental splints or prosthesis, emotional support services and evaluation and planning for surgery. Orthodontic preparation is begun at this time.

Month Three

Cleft lip repair

Months Three to Twelve

Construction of further dental splints if indicated, one or more hearing/ear evaluations and speech evaluation

One year of Age

Cleft palate repair and placement of ear tubes, if necessary

One to Five Years of Age

Periodic (e.g., annual or bi-annual) clinic evaluation of speech (if abnormal, speech therapy is started through school or clinic), hearing, dentition and social/emotional development.

Occasionally, palate and lip revision surgery is required and is performed during this period. Frequently, this surgery is combined with nasal surgery that is performed before the child starts school. Every attempt is made to minimize the child’s deformity prior to beginning school.

Five to Nine Years of Age

Cleft patients typically require orthodontic preparation for surgical bone graft of the cleft in the palate before permanent teeth erupt. This is performed during this period. When adequately prepared, the bone graft procedure is performed to move bone from the hip to the bone hole in the palate. Also, the speech assessment is continued during this time.

Nine to Twenty Years of Age

Orthodontic treatment is continued, and if necessary, minor lip and nose revisions are performed. When the jaw is fully grown (typically in the late teen years) jaw and final nasal surgery is performed if necessary.

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Treatment Protocol: Craniofacial Disorders

(There are many different types of craniofacial anomalies and therefore this protocol is meant to be a general outline only.)

Month One

Clinic visit for general pediatric evaluation with emphasis on feeding difficulties, hearing problems, genetic counseling, dental evaluation, eye evaluation and possible construction of dental splints or prostheses, emotional support services and evaluation and planning for surgery. X-rays and CAT scans are typically performed to define the exact nature of the disorder.

Three to Six Months of Age

Helmet therapy is begun to remodel the skull for babies with “crooked” skulls or plagiocephaly.

Six to Twenty Four Months of Age

Surgery may be needed to remold and reshape the skull or upper face. This is performed as a joint procedure between the craniofacial surgeon and the neurosurgeon usually at 6-12 months of age. For children with poor skull growth, a second operation is considered during this period to ensure that brain growth is not restricted. In general, we try to correct the skull defects as soon as possible to take advantage of the younger child’s advantage in healing and remodeling bone.

Two to Five Years of Age

For children with jaw deformities such as hemifacial microsomia, jaw stretching or distraction is typically performed at this age. Distraction typically requires two surgeries, one to place the instrument and one smaller operation to remove it. Our team routinely uses distraction instruments placed totally inside the mouth and avoids scars on the cheek whenever possible.

For children with impaired facial growth (typically seen in Apert’s, Crouzon’s and other disorders) facial advancement surgery is performed during this period.
Also during this period, speech, dental, eye, and ear evaluations are performed annually or bi-annually as needed.

After Five years of Age

Close, continued evaluation of the speech, teeth, eyes, and ears are performed on an annual or bi-annual basis as needed. Orthodontic treatment is begun if necessary leading toward final nasal and jaw surgery late in the teenage years.

To read more about cleft lip and palate as well as other craniofacial procedures offered by the surgeons at HNSA, please visit: http://www.plasticsurgery.org/public_education/procedures/CleftLipPalate.cfm.

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Facial Trauma Surgery

HNSA’s surgeons are all members of Legacy Emanuel Hospital's Level 1 Trauma Team and have extensive experience managing patients with severe maxillofacial, head and neck injuries. With academic appointments at Oregon Health & Science University, our surgeons are also heavily involved in education and research and have published extensively on the subject of maxillofacial trauma.

The physicians and surgeons at HNSA are uniquely qualified to manage patients with facial injuries, as well as to treat the numerous cosmetic and functional deformities that can occur as a result of complex facial trauma. The face is a complicated structure that provides individuals with their primary sense of esthetic beauty, unique appearance and self esteem. Trauma to the facial region frequently results in injuries to the soft tissue, bony skeleton, jaws, mouth, teeth, lips, nose, eyes and ears. Our physicians are both medical doctors, as well as dentists, and are trained to reconstruct the face and jaws from both a cosmetic and functional standpoint.

Regardless if the injured patient requires primary soft tissue or skeletal repair, bone grafting or soft tissue reconstruction, dental implants to restore lost teeth and occlusion, or facial cosmetic surgery, the surgeons at Head & Neck Surgical Associates will provide the most comprehensive patient care, utilizing the most contemporary techniques and technology available in the world today.

To learn more about the trauma system at Legacy Emanuel Hospital and Health Center, please visit: http://www.legacyhealth.org/body.cfm?id=54&oTopID=0.

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Snoring and Sleep Apnea Surgery

Head & Neck Surgical Associates offers comprehensive, state-of-the-art treatment for patients with sleep disordered breathing, including radiofrequency ablation, laser assisted uvulopalatoplasty (LAUP), uvulopalatopharyngoplasty, septoplasty, genioglossal advancement, maxillomandibular advancement and tracheostomy.

Our physicians are part of the first group of surgeons in Portland to offer comprehensive treatment for all types of sleep disordered breathing including snoring and obstructive sleep apnea. Treatment is individualized for each patient depending upon the etiology and severity of the underlying disorder. Often, patients complaining of “snoring” may have underlying medical conditions or severe obstructive sleep apnea that will impact the treatment recommendation. Patients with obstructive sleep apnea that is documented on a sleep study are initially treated with CPAP. Those patients who fail, or cannot tolerate CPAP, are candidates for surgical treatment. Our practice philosophy generally consists of a staged approach in an effort to perform the smallest operation possible in order to achieve a cure.

Snoring

It is estimated that 40 million Americans snore at some time during their lives. Even more people are affected if you consider the sleeping partners of those who habitually snore. Significant snoring is sometimes so severe that it may be heard more than two bedrooms away.

Snoring is not sleep apnea, and sleep apnea is not snoring. Snoring is a social problem, which may involve considerable sleep disturbance, waking episodes, etc., without obstructive sleep apnea. However, many patients with loud snoring, may also have obstructive sleep apnea.

Treatment decisions are based on whether significant apnea exists. For snorers, treatment can include non-surgical or surgical approaches. Non-surgical options include weight loss and positional changes (keeping snorer off his/her back). Surgical methods include Laser-Assisted Uvulopalatoplasty (LAUP) or radiofrequency ablation treatments.

Obstructive Sleep Apnea Syndrome

Obstructive Sleep Apnea Syndrome (OSAS) is characterized by frequent breathing interruptions (airway obstructions) during the night. When breathing stops, there may be a significant decrease in blood oxygen levels and cardiac arrhythmia (irregularities in the heart's normal beating pattern) may occur. In extreme cases, the result can be death. OSAS is a serious disorder, which can become a major health risk. Long-term effects can include both lung and heart problems. On a less drastic level, these disturbances may prevent the brain from entering the restorative REM sleep stage, leading to mood, memory and concentration problems.

Treatment options for patients with OSAS include weight loss, positional changes while sleeping, Continuous Positive Airway Pressure (CPAP), or Uvulopalatopharyngoplasty (UPPP or UP3), septoplasty, or maxillomandibular advancement surgery.

• CPAP—Continuous Positive Airway Pressure, or CPAP, is the only non-surgical treatment for OSAS. With CPAP, pressurized air is administered using a facemask, which is worn while sleeping. The pressure of the air creates a clear airway. CPAP is effective in reducing the number of apneic episodes. Many patients find that while wearing this device, they experience a much improved sleep pattern with an overall better night's sleep. For others, however, the CPAP device is cumbersome and difficult to use. Some patients use CPAP for a while, and then choose surgical therapy because of the difficulty in consistently using the device.
• LAUP—Laser assisted uvulopalatoplasty (LAUP) is a surgical method used to treat mild-to-severe snorers and those with very mild OSAS. This procedure utilizes a laser beam to remove and tighten floppy soft palate tissue in the back of the mouth, thereby reducing the amount that these tissues contribute to snoring. This procedure, although surgical, can be performed in an outpatient setting. Most patients find that postoperative discomfort is mild, equivalent to a few days' worth of a sore throat. Many people find that their snoring is significantly reduced and sometimes eliminated through the LAUP. Some patients do however require multiple LAUP treatments to effectively eliminate severe snoring.
• Radiofrequency ablation (Somnoplasty)—Somnoplasty is a surgical therapy for snoring (not OSAS). The treatment is performed in our office under local anesthesia. Somnoplasty is a minimally invasive treatment which may result in less postoperative pain than traditional surgical snoring therapies.
  Radiofrequency ablation reduces snoring in two important ways: first, by removing a small amount of tissue via a patented process of molecular disintegration; and second, by heating tissue to cause controlled shrinkage and stiffening of the soft palate. Laser therapies, while similar in aim, are very different in their method of action. Laser snoring therapies involve cutting into the soft palate. With Somnoplasty, there is no cutting, only molecular disintegration and tissue shrinkage.
• UPPP—Uvulopalatopharyngoplasty (UPPP) has been the mainstay in the surgical treatment of severe snoring and OSAS. Thousands of patients have been effectively treated with this technique. While UPPP does not cure all OSAS, it will significantly reduce the degree of OSAS in over 50-60 percent of patients, and usually eliminates, or significantly reduces, snoring. Those patients who do not experience a significant correction of the OSAS may need to undergo other surgical treatment. Most people do, however, experience an improvement in their sleep patterns and overall quality of life.
• Maxillo-mandibular advancement (Orthognathic surgery)—Patients who fail CPAP, as well as soft tissue reduction surgeries such as UPPP, are candidates for maxillo-mandibular (skeletal) advancement surgery. This surgical technique involves osteotomies (bone cuts) to reposition the jaws forward in an effort to “open the airway.” The procedure ideally involves combined orthodontic treatment to finalize the occlusion (bite). The treatment results for maxillo-mandibular advancement have been shown to be superior to all other techniques (except tracheostomy) and is curative in more than 90 percent of the patients. Our surgeons have extensive experience in this type of maxillofacial surgery.

To read more about surgery for snoring and obstructive sleep apnea, please visit http://www.entnet.org/healthinfo/snoring/snoring.cfm .

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Tempormandibular Joint (TMJ) Disorders & Surgery

The surgeons of Head & Neck Surgical Associates have extensive experience with both surgical and non-surgical management of patients with temporomandibular joint (TMJ) disorders, and continue to attract patients from across the country. Treatment generally involves a multidisciplinary approach and includes close consultation with restorative dentists, orthodontists, and physical therapists.

Temporomandibular Joint (TMJ) dysfunction and disorders are related to the complex jaw joint. Symptoms usually come in the form of clicking, popping and pain in the ear and jaw area. Difficulty in eating, tightness and spasm within the muscles of the face are early indications of problems. This may lead to jaw locking and inability to eat without pain. The reason that this area of treatment is so complex is not only is the jaw joint itself a problem, but its intimately connected to the bite. A bad bite or misaligned occlusion tends to complicate the problem. Therefore, there is no simple treatment and/or prescription for your temporomandibular joint problem. Restoring your jaw function to a harmonious and pain free situation is complex and may include several kinds of treatments to restore health and normal function.

Depending upon the particular diagnosis, treatment may involve various medications, diet restrictions, physical therapy, dental splints, orthodontics, and/or surgery.

Non-surgical Treatment

• Medications, splints and physical therapy—The foundation of treatment of most TMJ disorders includes the use of non-steroidal anti-inflammatory medications, a soft diet and the use of a heating pad to alleviate pain. Initially, and for early stage treatment, occlusal splint therapy is used. This is a dental splint that acts as an anterior positioning device that moves the lower jaw ever so slightly forward. However, it is enough to take pressure off the joint area and provide relief from pressure on the jaw. It is worn 24 hours a day for a three to six month period. In conjunction with this splint therapy, physical therapy is added to the regimen in order to achieve muscle relaxation and to decrease clenching and pressure upon the joints. Should this device be successful, treatment options such as bite correction can be entertained.
• Orthodontics and restorative dentistry—Orthodontics and occasionally restorative dentistry is a treatment option that works by repositioning the teeth to stabilize the bite. This is generally recommended following successful splint therapy. Missing teeth need to be replaced with bridges and/or implants; crowns and occasionally orthodontics is combined with a surgical procedure to reposition the jaws.

Surgical Treatment

• Arthrocentesis—Arthrocentesis is a relatively minor outpatient surgical procedure that is recommended for patients with acute internal derangements or inflammatory conditions of the TMJ. It is a lavage (“washing out”) of the joint space using needles and injections of saline and steroid and is designed to remove the mediators of inflammation, decrease pain and improve function in patients with various TMJ disorders. It is an outpatient procedure performed under IV sedation in an office setting.
• Arthroscopy—Arthroscopy of the TMJ is similar to arthrocentesis, however, it involves the use of an endoscope in order to directly visualize the joint space and assist in direct repair of internal joint derangements or the removal of scar tissue within the joint. Arthroscopy is performed under a general anesthetic on an outpatient basis.
• Arthroplasty—TMJ arthroplasty implies an “open procedure” that is performed under a general anesthetic for patients with painful internal derangements and advanced joint degeneration. This procedure is highly successful for relieving pain and improving jaw function and is generally performed on an outpatient basis. No foreign materials are used, and if necessary, the joint meniscus may be reconstructed utilizing cartilage harvested (taken) from the ear.
• Total joint reconstruction—Surgeons at HNSA have pioneered the use of the 2nd metatarsal to TMJ joint replacement procedure as an alternative to alloplastic (metal) TMJ reconstruction. This procedure involves taking the second toe and a portion of the blood supply to this area and using it to replace the degenerative or mutilated TMJ. This type of microvascular reconstruction provides a “living joint” that is designed to improve the quality of life, decrease pain and optimize function in patients who have few alternatives and chronic discomfort.

To learn more about treatment of TMJ disorders, please visit http://www.aaoms.org/pamphlets.cfm.

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