Patent Publication Number: US-2019175882-A1

Title: Paranasal sinus access implant devices and related tools, methods and kits

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application is a continuation of U.S. patent application Ser. No. 15/424,999 entitled “PARANASAL SINUS ACCESS IMPLANT DEVICES AND RELATED TOOLS, METHODS AND KITS” having a filing date of Feb. 6, 2017, which is a continuation of U.S. patent application Ser. No. 14/424,841 entitled “PARANASAL SINUS ACCESS IMPLANT DEVICES AND RELATED TOOLS, METHODS AND KITS” having a 371(c) date of Feb. 27, 2015, which is a U.S. national stage filing under the Patent Cooperation Treaty of international patent application no. PCT/US2014/012995 filed Jan. 24, 2014, which claims the benefit of U.S. provisional patent application No. 61/757,046 entitled “IMPLANT DEVICE, METHOD AND KIT FOR IMPLANTATION BETWEEN THE LACRIMAL SYSTEM AND A PARANASAL SINUS” filed Jan. 25, 2013 and the benefit of U.S. provisional patent application No. 61/891,250 entitled “PARANASAL SINUS ACCESS IMPLANT DEVICES AND RELATED TOOLS, METHODS AND KITS” filed Oct. 15, 2013, and the entire contents, and each and every portion thereof, of each of the foregoing identified applications is incorporated by reference herein. 
     This application incorporates by reference each and every portion of the following: international patent application no. PCT/US2011/055456 entitled “IMPLANT DEVICE, TOOL, AND METHODS RELATING TO TREATMENT OF PARANASAL SINUSES” filed Oct. 7, 2011 (which entered the PCT national stage in the U.S. as U.S. patent application Ser. No. 13/877,893 and is now issued as U.S. Pat. No. 9,308,358); U.S. nonprovisional patent application Ser. No. 13/225,213 (now issued as U.S. Pat. No. 9,022,967) entitled “IMPLANT DEVICE, TOOL, AND METHODS RELATING TO TREATMENT OF PARANASAL SINUSES” filed Sep. 2, 2011; U.S. provisional patent application No. 61/528,058 entitled “IMPLANT DEVICE, TOOL, AND METHODS RELATING TO TREATMENT OF PARANASAL SINUSES” filed Aug. 26, 2011; U.S. provisional patent application No. 61/404,716 entitled “METHODS AND TOOLS FOR TREATMENT AND PREVENTION OF SINUSITIS” filed Oct. 8, 2010; U.S. provisional patent application No. 61/623,022 entitled “IMPLANTATION TOOLS, TOOL ASSEMBLIES, KITS AND METHODS” filed Apr. 11, 2012; and international patent application no. PCT/US2013/03447 entitled “IMPLANTATION TOOLS, TOOL ASSEMBLIES, KITS AND METHODS” filed Mar. 28, 2013. 
    
    
     FIELD OF THE INVENTION 
     The invention relates to treatment of conditions of the paranasal sinuses, including with respect to paranasal sinus access implant devices, surgical tools, methods and kits. 
     BACKGROUND OF THE INVENTION 
     In the United States alone, 35 million people a year are treated for sinus infections, or sinusitis, and 7 million of those will suffer from chronic sinusitis and will have minimal response to prescription drug therapies. Conventional surgical interventions may be expected to, at best, offer only moderate symptomatic improvement but no cure. 
     Conventional drug therapies include oral administration as pills and nasal topical administration, neither of which is conducive to delivering adequate concentration of medication to the involved paranasal sinus. In addition to medication, frequent sinus irrigation can be helpful in flushing out debris, irritants and obstructing viscous fluids, but patients are generally not able to adequately perform this procedure at home. 
     For patients with particularly severe symptoms, surgical drainage has been an option of last resort. An early surgical procedure was the Caldwell-Luc procedure, which involves creating a permanent fistula from the base of the paranasal sinus into the oral cavity above the front upper incisors. More recently, other surgical access points to the paranasal sinuses have been attempted. A variety of endoscopic techniques have been developed that access the paranasal sinuses through the nose, including functional endoscopic sinus surgery (FESS) and balloon sinuplasty. All attempt to increase drainage, but utilize different routes or tools. Surgical formation of a fistula between the lacrimal apparatus and a paranasal sinus has been identified as a technique to provide direct access to the paranasal sinus, and through which a variety of medical treatments and medical procedures may be directed to the paranasal sinus. None of these surgical approaches has yet achieved wide-spread acceptance or success, and millions of chronic sinusitis patients continue to suffer long-term disability and discomfort. 
     SUMMARY OF INVENTION 
     Paranasal sinus access implant devices may be configured to be implanted in a human to provide fluid access to a paranasal sinus through an internal passage of such a paranasal sinus access implant device. Such paranasal sinus access implant devices have significant potential for performance of medical procedures and treatments of paranasal sinuses, but such potential has not yet been realized, and there is a continued need for implant devices and accompanying procedures that facilitate easy and effective implantation with good anchoring of the implant device, patient comfort, implant device durability post implantation and effective performance of medical procedures. Various aspects of this disclosure relate to paranasal sinus access implant devices, tools and methods for implantation procedures and treatments through implanted implant devices and kits including paranasal sinus access implant devices. For brevity, paranasal sinus access implant devices are sometimes referred to herein as simply implant devices. 
     A first aspect of the disclosure involves an implant device useful for implantation in a human to fluidly connect a lacrimal apparatus to a paranasal sinus through a fistula formed between the lacrimal apparatus and the paranasal sinus. 
     It has been found that implant devices may be better retained following implantation if the implant devices include anchoring surface features including protrusion areas and recess areas along a conduit that is to be inserted into the fistula for implantation. Anchoring is enhanced when a maximum outside diameter defined by protrusion areas to be disposed in the fistula is larger than the diameter of the fistula that was formed to accept the conduit of the implant device. This creates a snug fit of the conduit in the fistula, with tissue forcing itself into the recess areas of the anchoring surface feature. However, such implantation conduits made of relatively flexible plastic materials may bunch up, such as in the manner of an accordion, making it difficult to insert the conduit into the fistula for implantation. It has been found that by including a thicker conduit wall in a proximal portion of the conduit of an implant device than is included in a distal portion that is inserted first into the fistula, that the ease of insertion of the conduit may be significantly improved. In addition, a thicker conduit wall in a proximal portion of the conduit provides added mechanical durability of the conduit adjacent the proximal end of the implant device and reducing potential for mechanical damage to proximal portions of the conduit due to mechanical interactions that may occur between the implant device and tools used during an implantation procedure or during performance of medical treatments and other procedures following implantation. 
     The implant device of the first aspect may include: 
     a proximal end at a first longitudinal end of the device; 
     a distal end at a second longitudinal end of the device that is longitudinally opposite the first longitudinal end; 
     a conduit located between the proximal end and the distal end; 
     an internal passage through the conduit; 
     a length of the implant device longitudinally along the implant device between the proximal end and the distal end in a range of from 2 millimeters to 50 millimeters; 
     a width of the internal passage transverse to the length in a range of from 0.25 millimeter to 5 millimeters; 
     the conduit including a first longitudinal portion and a second longitudinal portion located toward the distal end relative to the first longitudinal portion; 
     the first longitudinal portion of the conduit having a minimum wall thickness (first minimum wall thickness) adjacent the internal passage; and 
     the second longitudinal portion of the conduit having a minimum wall thickness (second minimum wall thickness) adjacent the internal passage that is smaller than the first minimum wall thickness; 
     the implant device configured to be implanted to fluidly connect the lacrimal apparatus to the paranasal sinus so that when implanted:
         the proximal end is disposed in the lacrimal apparatus;   the distal end is disposed in the paranasal sinus; and   the conduit is disposed through the fistula with at least a portion of each of the first longitudinal portion and the second longitudinal portion of the conduit disposed within the fistula and with at least a portion of the second longitudinal portion of the conduit disposed in the paranasal sinus.       

     A number of feature refinements and additional features are applicable to the first aspect of the disclosure. These feature refinements and additional features may be used individually or in any combination within the subject matter of the first aspect or any other aspect of the disclosure. As such, each of the following features may be, but are not required to be, used with any other feature or combination of features of the first aspect or any other aspect of the disclosure. 
     The first longitudinal portion of the conduit may or may not have a uniform wall thickness. The first longitudinal portion of the conduit may have a smooth exterior surface. The first longitudinal portion of the conduit may have a length of at least 3 millimeters, at least 4 millimeters, at least 5 millimeters, at least 8 millimeters or at least 10 millimeters. The first longitudinal portion of the conduit may often have a length that is no greater than 20 millimeters, no greater than 15 millimeters, no greater than 12 millimeters or no greater than 10 millimeters. 
     The first minimum wall thickness may be at least 0.25 millimeter, at least 0.3 millimeter, at least 0.35 millimeter or at least 0.4 millimeter. The first minimum wall thickness may often be no greater than 0.75 millimeter, no greater than 0.6 millimeter, no greater than 0.55 millimeter, no greater than 0.5 millimeter or no greater than 0.45 millimeter. The wall thickness of the first longitudinal portion of the conduit may be substantially the same and equal to the first minimum wall thickness over some portion of or the entire length of the first longitudinal portion. 
     The second longitudinal portion of the conduit may have a length of at least 3 millimeters, at least 4 millimeters, at least 5 millimeters, at least 8 millimeters or at least 10 millimeters. The second longitudinal portion of the conduit may often have a length that is no greater than 30 millimeters, no greater than 25 millimeters, no greater than 20 millimeters, no greater than 15 millimeters, no greater than 12 millimeters or no greater than 10 millimeters. 
     The second minimum wall thickness may be no greater than 0.6 millimeter, no greater than 0.5 millimeter, no greater than 0.45 millimeter, no greater than 0.4 millimeter, no greater than 0.35 millimeter, no greater than 0.3 millimeter, no greater than 0.25 millimeter or no greater than 0.2 millimeter. The second minimum wall thickness may often be at least 0.1 millimeter, at least 0.15 millimeter or at least 0.2 millimeter. The wall thickness of the second longitudinal portion of the conduit may be substantially the same over some portion or portions of the second longitudinal portion of the conduit. The second longitudinal portion of the conduit may have an exterior including an anchoring surface feature including protrusion areas and recess areas. The wall thickness at locations corresponding with the recess areas may be smaller than the wall thickness at locations corresponding with the protrusion areas. The second minimum wall thickness may occur at one or more locations corresponding with one or more of such recess areas. 
     The first minimum wall thickness may be at least 0.05 millimeter larger, at least 0.1 millimeter larger, at least 0.15 millimeter or at least 0.175 millimeter larger than the second minimum wall thickness. The first minimum wall thickness may be no more than 0.3 millimeter larger, no more than 0.25 millimeter larger or no more than 0.2 millimeter larger than the second minimum wall thickness. 
     The first longitudinal portion of the conduit may have a maximum exterior width (first maximum exterior width) that is smaller than a maximum exterior width of the second longitudinal portion of the conduit (second maximum exterior width). The second maximum exterior width may be at least 0.1 millimeter larger, at least 0.2 millimeter larger, at least 0.25 millimeter larger, at least 0.3 millimeter larger, at least 0.35 millimeter larger, at least 0.4 millimeter larger or at least 0.5 millimeter larger than the first maximum exterior width. The second maximum exterior width may often be no more than 1 millimeter, no more than 0.75 millimeter, no more than 0.5 millimeter or no more than 0.4 millimeter larger than the first maximum exterior width. The first maximum exterior width may be at least 1.25 millimeters, at least 1.5 millimeters, at least 1.75 millimeters or at least 2 millimeters. The first maximum exterior width may often be no greater than 3 millimeters, no greater than 2.5 millimeters, no greater than 2.25 millimeters or no greater than 2 millimeters. The second maximum exterior width may be at least 1.5 millimeters, at least 1.6 millimeters at least 1.75 millimeters, at least 2 millimeters, at least 2.25 millimeters or at least 2.5 millimeters. The second maximum exterior width may be no greater than 5 millimeters, no greater than 4 millimeters, no greater than 3 millimeters, no greater than 2.75 millimeters, no greater than 2.5 millimeters or no greater than 2.25 millimeters. 
     The first longitudinal portion of the conduit may have a minimum exterior width (first minimum exterior width) and the second longitudinal portion of the conduit may have a minimum exterior width (second minimum exterior width) that is smaller than the first maximum exterior width. The first minimum exterior width may be at least 0.1 millimeter larger, at least 0.2 millimeter larger, at least 0.25 millimeter larger, at least 0.3 millimeter larger, at least 0.35 millimeter larger, at least 0.4 millimeter larger or at least 0.5 millimeter larger than the second minimum exterior width. The first minimum exterior width may be no greater than 3 millimeters, no greater than 2.5 millimeters, no greater than 2.25 millimeters or no greater than 2 millimeters. The first minimum exterior width may be at least 1 millimeter, at least 1.25 millimeters, at least 1.5 millimeters, at least 1.75 millimeters or at least 2 millimeters. The first longitudinal portion of the conduit may have a substantially constant cross-section (e.g., constant circular cross-section), in which case the maximum and minimum exterior widths of the first longitudinal portion of the conduit are the same (e.g., diameter of constant circular cross-section). The second minimum exterior width may be no greater than 2.5 millimeters, no greater than 2 millimeters, no greater than 1.75 millimeters or no greater than 1.5 millimeters. The second minimum exterior width may often be at least 1 millimeter, at least 1.25 millimeter, at least 1.50 millimeters or at least 1.75 millimeters. The second longitudinal portion may have a surface geometry wherein the second minimum exterior width may be smaller than a second maximum exterior width of the second longitudinal portion. The second minimum exterior width may correspond with locations of the second minimum wall thickness. 
     The conduit may have a circular cross-section at some or all points along the length of the first and second longitudinal portions of the conduit. The first minimum wall thickness and the second minimum wall thickness may be tubular walls. 
     The conduit may be configured so that an exterior of the conduit comprises an anchoring surface feature that assists to anchor the implant device when the device is implanted. The anchoring surface feature includes protrusion areas and recess areas. The second minimum wall thickness may occur at a location corresponding with at least one of the recess areas. The implant device may be configured so that when implanted the conduit is disposed through the fistula with at least a portion of the recess areas disposed within the fistula and with at least a portion of the protrusion areas disposed in the fistula and engaging tissue exposed within the fistula to anchor the implant device. The structural and mechanical characteristics of protrusion occurrences in the protrusion areas may affect anchoring performance of the protrusion areas. The height of the protrusion areas relative to the recess areas may affect anchoring effectiveness when the implant device is implanted. A larger height may provide greater anchor effectiveness, but also may involve a larger overall width of the implant device that must be inserted into the fistula. The protrusion areas may have a height relative to the recess areas of at least 0.1 millimeter, at least 0.2 millimeter, at least 0.25 millimeter or at least 0.3 millimeter. The protrusions areas may have a height relative to the recess areas of no greater than 2 millimeters, no greater than 1.5 millimeter, no greater than 1 millimeter, no greater than 0.75 millimeter, no greater than 0.5 millimeter or no greater than 0.4 millimeter. The height may be of particular protrusion occurrences relative to adjacent areas of recesses. Protrusion occurrences are also referred to herein as anchor protrusions. Such anchor protrusions may be configured to flexibly deform when the conduit is inserted through the fistula for implantation, for example to flexibly deform in a direction opposite the direction of insertion when the anchor protrusions contact tissue disposed in the fistula during insertion. After insertion, the anchor protrusions may over time return to their original shape and extend deeper into adjacent tissue to better anchor the implant device. The mechanical properties of the anchor protrusions may be influenced by materials of construction. Preferred materials of construction for the protrusion areas, and also for the other portions of the implant device, are polymeric materials. The polymeric materials may preferably be medical grade materials. Some preferred polymeric materials are silicones and polyurethanes. For enhanced performance, the material of construction should have a rigidity that interacts positively with tissue in the vicinity of the fistula, for example to promote load sharing and good anchoring. One preferred material of construction is a polymeric material (e.g. silicone or polyurethane) having a durometer (Shore A) in a range having a lower limit of 50, 60, 70 or 80 and an upper limit of 100, 80, 70 or 60, provided that the upper limit must be larger than the lower limit. One preferred range is for a durometer (Shore A) of 60-100, with a range of 80-100 being even more preferred. For some implementations the polymeric material has a durometer (Shore A) of about 60, of about 80 or of about 100. Mechanical properties of the protrusion occurrences of the protrusion areas will also be affected by the geometry of the protrusion occurrences. The protrusion occurrences may have a width that tapers, or narrows, in a direction from a base toward a top of the protrusion occurrences, with the base being a portion of a protrusion occurrence disposed toward the internal passage of the conduit and a top of the protrusion occurrence being the extremity of the protrusion occurrence away from the internal passage of the conduit. The width may be transverse to the length of the conduit. The protrusion occurrences may have a width at the base that is no larger than 2 millimeters, no larger than 1.5 millimeters, no larger than 1.25 millimeters or no larger than 1 millimeter. One or more of the protrusion occurrences may have a width at the base that is at least 0.2 millimeter, at least 0.3 millimeter, at least 0.5 millimeter, at least 0.75 millimeter or at least 1 millimeter. The protrusion occurrences may have a width adjacent the top that is no larger than 0.75 times width at the base, no larger than 0.5 times the width at the base, or no larger than 0.25 times the width at the base. The protrusion occurrences may have a width midway between the base and the top that is no larger than 0.8 times the width of the base, no larger than 0.7 times the width of the base, no larger than 0.6 times the width of the base or no larger than 0.5 times the width at the base. 
     The protrusion areas may be provided by a single protrusion occurrence feature located to correspond with the interior of the fistula when the implant device is implanted. In more preferred implementations, the protrusion areas include multiple protrusion occurrences spaced on the exterior of the conduit. The protrusion occurrences may have a center-to-center spacing, in one or more directions, of at least 0.5 millimeter, at least 0.75 millimeter, at least 1 millimeter or at least 1.75 millimeters. The protrusion occurrences may have a center-to-center spacing of no greater than 2.5 millimeters, no greater than 2 millimeters or no greater than 1.75 millimeters. The protrusion occurrences may have a center-to-center spacing longitudinally along the conduit. The protrusion occurrences may have a center-to-center spacing that is at least 0.5 times the base width of the protrusion occurrences, or at least 1 times the base width of the protrusion occurrences or at least 2 times the base width of the protrusion occurrences. The protrusion occurrences may have a center-to-center spacing that is no more than 5 times a base width of the protrusion occurrences, no more than 3 times a base width of the protrusion occurrences or no more than 2 times a base width of the protrusion occurrences. 
     The protrusion areas may be located on a longitudinal portion of the conduit that includes at least a portion of the conduit that will be disposed within a fistula when the implant device is implanted. The protrusion areas may be on a longitudinal portion of the conduit that extends for at least 2 millimeters along the length of the implant device, that extends for at least 3 millimeters along the length of the implant device, that extends for at least 4 millimeters along the length of the implant device, that extends for at least 5 millimeters along the length of the implant device or that extends for at least 8 millimeters along the length of the implant device. A longitudinal portion of the conduit including the protrusion areas may be no longer than 20 millimeters, no longer than 15 millimeters or no longer than 10 millimeters. A longitudinal portion of the conduit including the protrusion areas may be disposed at least 2 millimeters from the proximal end of the device, at least 3 millimeters from the proximal end of the device, or at least 4 millimeters from the proximal end of the device. When the implant device has a head, a longitudinal portion of the conduit including the protrusions may be disposed at least 1 millimeter, at least 2 millimeters or at least 3 millimeters from the head. Providing significant distance between the head and commencement of the protrusion areas permits the head to better “float” on the surface of tissue, which may enhance patient comfort and device performance. The protrusion areas may be disposed along a longitudinal portion of the conduit with the protrusion areas covering no more than 35% of the area along that longitudinal portion of the conduit, no more than 25% of the area along that longitudinal portion of the conduit or not more than 20% of the area along that longitudinal portion of the conduit. Providing significant spacing between protrusion occurrences may permit better engagement of tissue by the anchoring surface feature. Some or all of the protrusion occurrences may be on the second longitudinal portion of the conduit. 
     The protrusion areas may comprise at least one circumferential ridge. By circumferential ridge is meant a ridge that extends around an entire circumference of the conduit. The protrusion area may comprise at least two, at least three or at least five circumferential ridges. The protrusion areas may comprise a spiral ridge. Such a spiral ridge may extend along a longitudinal portion of the conduit. The protrusion areas may comprise a knob or may comprise multiple knobs. The anchoring surface feature may comprise a textured surface, with the protrusion areas comprising protruding portions of the textured surface and the recess areas comprising recess portions of the textured surface. 
     The length of the implant device may be selected to provide sufficient conduit length for extending through the entire length of the fistula plus any extension distance desired in the lacrimal apparatus proximal to the fistula and in the paranasal sinus distal to the fistula. The length of the implant device and/or of the conduit may be in a range having a lower limit of 2 millimeters, 3 millimeters, 4 millimeters, 5 millimeters, 8 millimeters, 10 millimeters or 12 millimeters and an upper limit of 50 millimeters, 40 millimeters, 30 millimeters, 25 millimeters, 20 millimeters, 15 millimeters or 10 millimeters, provided that the upper limit is larger than the lower limit. One preferred range for some implementations when the fistula is between the orbit and the ethmoid sinus or the maxillary sinus is for the length of the implant device and/or for the length of the conduit to be in a range of from 10 millimeters to 30 millimeters, with a range of from 15 millimeters to 25 millimeters being more preferred. By length of the implant device or conduit it is meant the dimension longitudinally along the implant device or the conduit, as the case may be, from the proximal end to the distal end of the implant device or conduit, and may be along a longitudinal axis through the internal passage. The length may be a straight line, for example when the internal passage is straight, or the length may be curvilinear or some other shape, for example when the internal passage is not linear. When a reference is made herein to transverse to the length, the reference is to a right angle to the longitudinal direction of the length at that point (e.g., right angle to a line of the length or to a line tangent to a curve of the length). 
     The implant device may advantageously be designed with a conduit of appropriate width dimensions to fit snuggly within a desired size of fistula. The implant device may have a first exterior width dimension defined by a maximum extent of the protrusion areas transverse to the length of the device, with the first exterior width being within a range having a lower limit of 0.75 millimeter, 1 millimeter, 1.25 millimeters, 1.5 millimeters, 1.75 millimeters or 2 millimeters and an upper limit of 8 millimeters, 7 millimeters, 6 millimeters, 5 millimeters, 4 millimeters, 3 millimeters, 2 millimeters or 1.75 millimeters, provided of course that the upper limit must be larger than the lower limit. The conduit may have a second width dimension defined by the minimum extent of the recess areas transverse to the length of the device, and which second exterior width dimension will be smaller than the first exterior width dimension defined by the protrusion areas. The second exterior width dimension defined by the recess areas may be smaller than the exterior width dimension defined by the protrusion areas by an amount within a range having a lower limit of 0.2 millimeter, 0.25 millimeter, 0.35 millimeter or 0.5 millimeter and having an upper limit of 1.5 millimeters, 1 millimeter or 0.75 millimeter. The height of the protrusion areas may be one-half the difference between the first exterior width and the second exterior width. Either one of or each one of the first exterior width and the second exterior width may be the diameter of a circle. 
     The implant device may include one or a plurality of side openings through the conduit wall of a distal portion of the conduit, which distal portion may be or include a portion of the conduit that is designed to be disposed within a paranasal sinus when the implant device is implanted to provide fluid access through the implant device to the paranasal sinus. The side openings may be open into the internal passage through the conduit and may provide a passage for fluid communication between the internal passage of the implant device and the paranasal sinus even if the distal opening of the internal passage at the distal end of the conduit were to become blocked or restricted for some reason. One or more of the side openings may be through a wall of the second longitudinal portion of the conduit, and may be though a wall having the second minimum wall thickness. One or more of the side openings may be located within one or more recess areas of an anchoring surface feature of the conduit (e.g., between circumferential ridges). With a thinner minimum wall thickness in the second longitudinal portion of the conduit than the first longitudinal portion of the conduit, the second longitudinal portion of the conduit, and in particular near a distal end of the second longitudinal portion of the conduit, may be more prone to restriction due to collapse of the conduit at or near the distal end, and the side openings  850  provide an alternative fluid access to the paranasal sinus. 
     The implant device may include a head adjacent to the conduit at the proximal end of the implant device. The implant device may be configured so that when the implant device is implanted, the head is disposed in the lacrimal apparatus, and preferably with the head located in the orbit. The head may beneficially keep the implant device from migrating through the fistula toward the paranasal sinus following implantation of the implant device. The head may comprise a flanged tissue engagement surface on a side of the head disposed toward the conduit and configured to engage tissue outside of and adjacent to the fistula when the implant device is implanted. The flanged tissue engagement surface may be a flat surface. The flanged tissue engagement surface may have non-flat surface features configured to improve seating of the surface against tissue, such as for example to inhibit rotation of the implant device within the fistula after implantation. The head may have a face surface opposite the flanged tissue engagement surface and also disposed away from the conduit and disposed away from tissue engaged by the flanged tissue engagement surface when the implant device is implanted. The face surface may be substantially flat. The face surface may be disposed at the proximal end of the implant device and the internal passage may open at the face surface. The separation distance between the face surface and the flanged tissue engagement surface may be in a range having a lower limit of 0.25 millimeter, 0.5 millimeter or 0.75 millimeter and having an upper limit of 2 millimeters, 1.5 millimeters or 1 millimeter. Such separation distance need not be constant across the flanged tissue engagement surface and face surface. A maximum separation distance between the face surface and the flanged tissue engagement surface may be referred to as the depth of the head, and such depth may be in a range described above for the separation distance between the face surface and the flanged tissue engagement surface. The flanged tissue engagement surface need not be continuous and may be divided into multiple distinct surface portions. For example, the flanged tissue engagement surface may include a first flanged portion disposed to one side of the internal passage and a second flanged surface portion disposed to a second side of the internal passage that is opposite the first side. Each of the face surface and the flanged tissue engagement surface may have a length dimension that represents a maximum separation distance between points on an outer edge of the respective surface, and may each have a width dimension that is a maximum separation distance between points on the outer edge transverse to the length dimension. The length dimensions of the face surface and the flanged tissue engagement surface may be the same or may be different. The width dimensions of the face surface and the flanged tissue engagement surface may be the same or may be different. The face surface and the flanged tissue engagement surface may have corresponding outer edges. The length dimension of any or all of the face surface, the flanged tissue engagement surface and the head may be larger than a first exterior width of the conduit defined by an extent of the protrusion areas transverse to the length of the implant device, when the implant device includes an anchoring surface feature such as summarized above. The length dimension of any or all of the face surface, the tissue engagement surface and the head may be in a range having a lower limit of 1 millimeter, 2 millimeters, 3 millimeters, 4 millimeters or 5 millimeters and an upper limit of, 10 millimeters, 8 millimeters or 7 millimeters. The width dimension of any or all of the face surface, tissue engagement surface and the head may be in a range having a lower limit of 0.5 millimeter, 1 millimeter, 1.5 millimeters or 2 millimeters and an upper limit of 5 millimeters, 4 millimeters or 3 millimeters. The length dimension of any or all of the face surface, the flanged tissue engagement surface and the head may be at least 1 millimeter, at least 2 millimeters, at least 3 millimeters or at least 4 millimeters larger than such first exterior width of the conduit defined by an extent of the protrusion areas, when the implant device includes an anchoring surface feature such as summarized above. A ratio of the length of any of or all the face surface, the flanged tissue engagement surface and the head to such a first exterior width of the conduit may be at least 2. Such a ratio may be smaller than 4. The width of any or all of the face surface, the flanged tissue engagement surface and the head may be not larger than, or may be smaller than (e.g., by at least 0.1 mm or by at least 0.2 mm), such a first exterior width of the conduit defined by an extent of the protrusion areas, when the implant device includes an anchoring surface feature such as summarized above. A ratio of the length dimension to the width dimension for any or all of the face surface, the flanged tissue engagement surface and the head may be in a range having a lower limit of 1, 1.5, 2 or 2.5 and an upper limit of 5, 4, 3 or 2.5, provided of course that the upper limit must be larger than the lower limit. Having a larger length dimension to width dimension on the head is particularly preferred when the head will be located in the orbit between the lacrimal caruncle and the plica semilunaris, because the length dimension may advantageously align in a vertical direction next to the eyeball and will help provide sufficient flanged surface area to effectively anchor the implant device on the proximal end and impede conjunctival tissue from covering the opening into the internal passage of the implant device, compensating for the narrower width. This is particularly advantageous when using polymeric materials of construction as described above. 
     The internal passage through the implant device may have a substantially uniform shape along the entire length of the implant device, or may have a varying shape. The internal passage may be substantially straight from the proximal end of the device to the distal end of the device. The internal passage may have a cross-section available for flow (transverse to the length of the device) that is substantially uniform from the proximal end to the distal end of the implant device. The internal passage may have a substantially circular cross-section. The internal passage may have a substantially elliptical cross-section. The width of the conduit (maximum dimension across the cross-section of the internal passage available for flow) may be in a range having a lower limit of 0.25 millimeter, 0.5 millimeter or 0.75 millimeter and 1 millimeter and an upper limit of 5 millimeters, or 4 millimeters or 3 millimeters, 2 millimeters or 1.5 millimeters. 
     The lacrimal apparatus and a paranasal sinus may be in fluid communication through the internal passage of the implant device when the implant device is implanted. The conduit may extend from adjacent the proximal end of the implant device. The conduit may extend to adjacent the distal end of the implant device. The internal passage may have a first end open at the proximal end and a second end open at the distal end, and when the implant device is implanted the first end of the internal passage may open in the lacrimal apparatus and the second end of the internal passage opens in the paranasal sinus 
     The implant device may be configured for implantation with the conduit passing through a fistula between a location in a lacrimal apparatus within the orbit and a paranasal sinus selected from the group consisting of a frontal sinus, an ethmoid sinus, a maxillary sinus and a sphenoid sinus, with a frontal sinus, a maxillary sinus or an ethmoid sinus being preferred, with an ethmoid sinus or a maxillary sinus being more preferred, and with an ethmoid sinus being particularly preferred. The implant device may be configured for implantation with the conduit passing through a fistula between a location in the lacrimal apparatus within the nasolacrimal duct and a paranasal sinus selected from the group consisting of an ethmoid sinus and a maxillary sinus. The location within the nasolacrimal duct may be within the lacrimal sac. 
     The implant device is primarily configured for and described herein with primary reference to the implant device being implantable in a fistula that may be formed between the lacrimal apparatus and a paranasal sinus to provide a passage from the lacrimal apparatus to the paranasal sinus. The implant device is also implantable in a fistula that may be formed between the lacrimal apparatus (e.g., from the corner of medial portion of the orbit between the lacrimal caruncle and the plica semilunaris) and the nasal cavity, for example for enhanced drainage of lacrimal fluid, and such applications directed to the nasal cavity are within the scope of the different aspects of the disclosure. 
     A second aspect of the disclosure involves an implantation kit with components for implantation of an implant device to provide an artificial fluid path in fluid communication with the lacrimal apparatus. A kit of the second aspect may include a paranasal sinus access implant device and at least one additional component useful in connection with implantation of the implant device or performance of a medical treatment or procedure through the implant device. 
     A number of feature refinements and additional features are applicable to the second aspect of the disclosure. These feature refinements and additional features may be used individually or in any combination within the subject matter of the second aspect or any other aspect of the disclosure. As such, each of the following features may be, but are not required to be, used within any other feature or combination of features of the first aspect, the second aspect or any other aspect of the disclosure. 
     The implant device may comprise:
         a proximal end and a distal end at opposite longitudinal ends of the implant device;   a conduit located between the proximal end and the distal end;   an internal passage extending through the conduit;   a longitudinal length between the proximal end and the distal end of the implant device in a range of from 2 millimeters to 50 millimeters;   a width of the internal passage transverse to the length in a range of from 0.25 millimeter to 5 millimeters; and   the implant device being configured to be implanted with the proximal end of the implant device disposed in the lacrimal apparatus and at least a portion of the conduit disposed in a fistula opening into the lacrimal apparatus.       

     The implant device may be an implant device of the first aspect of the disclosure or may have any feature or combination of features described for the first aspect of the disclosure, for example even if the implant device is not according to the first aspect. 
     A kit may include any, or any combination of any, apparatuses, tools, devices, products, components or treatment compositions described herein. 
     A kit may include a fluid treatment composition deliverable to a paranasal sinus through the implant device following implantation of the implant device to provide fluid access to the paranasal sinus. Such a fluid treatment composition may be suitable for being conducted to the internal passage of an implant device through manipulation of a fluid dispenser for delivery to a paranasal sinus, for example to treat for sinusitis or some other condition of the paranasal sinus. The treatment composition may be an aqueous irrigation liquid. The treatment composition may be a drug treatment composition. The drug treatment composition may comprise at least one drug for treating sinusitis or other condition of a paranasal sinus. The drug treatment composition may comprise one or more of the following: 
     an antibiotic, a steroid, an anti-viral, an antihistamine, an anti-fungal, a mast cell stabilizer, a mucolytic, a non-steroidal anti-inflammatory drug (NSAID), a vasoconstrictor and an immunosuppressant. Some example antibiotics include: sulfa, or sulfonamide, drugs, such as for example sulfacetamide (e.g., in OCUSOL) and sulfisoxazole (e.g., in GANTRISIN®); macrolide drugs, such as for example azithromycin (e.g., in AZACITE®) and erythromycin (e.g., in ERYPED®); aminoglycoside drugs, such as for example tobramycin (e.g., in TOBREX®) and gentamicin (e.g., in GENOPTIC®); fluoroquinolone drugs, such as for example ciprofloxacin (e.g., in CILOXAN®), besifloxacin (e.g., in BESIVANCE®) and moxifloxacin (e.g., in VIGAMOX®); tetracycline drugs, such as for example oxytetracycline (e.g., in CODEX); and antibiotic drug combinations, such as for example containing a combination of bacitracin, neomycin and polymyxin B (e.g., in OCUSPORE B) and a combination of gramicidin, neomycin and polymyxin B (e.g., in NEOCIN PG). Some example antivirals include gancyclovir (e.g., in ZIRGAN®) and trifluridine (e.g., in VIROPTIC®). Some example steroids include loteprednol (e.g., in LOTEMAX®) and prednisolone (e.g., in PRED FORTE®). Some example anthistimines include ketotifen (e.g., in ALAWAY®), otopatadine (e.g., in PATADAY®) and pinastine (e.g., in ELESTAT®). Some example mast cell stabilizers include nedocromil sodium (e.g., in ALOCRIL®) and lodoxamide (e.g., in ALOMIDE®). Some example anti-fungals include natamycin (e.g., in NATACYN®) and euconzol. Some example mucolytics include N-acetylcysteine (e.g., in PARVOLEX). Some example NSAID materials include nepafenac (e.g., in NEVANAC®) and bromfenac (e.g., in BROMDAY®). Some example vasoconstrictors include naphazoline (e.g., in NAPHCON A®) and tetrahydrozoline (e.g., in VISENE®) Some example immunosuppressants include cyclosporine (e.g., in RESTASIS®). All of the aforementioned materials include any pharmaceutically acceptable salts thereof. 
     The fluid treatment composition may be disposed within a fluid container as provided in the kit. The fluid container may contain any desired volume of the treatment composition. Such a volume may be in a range having a lower limit of 0.1, 0.25, 0.5, 0.75 or 1 milliliter and an upper limit of 5, 3 or 2 milliliters. Such a range may be the total treatment composition contained within the fluid container or may be the volume of treatment composition contained within the fluid container that is deliverable from the fluid container, which may be referred to as the deliverable volume. The deliverable volume refers to that volume of fluid in the fluid container that can be effectively delivered from a fluid dispenser. The delivery volume may be less than the total volume of treatment composition contained in the fluid container because of residual treatment composition that may be retained in the fluid container or within the fluid dispenser, for example residual treatment composition that may be adhered on internal wall surfaces of (e.g., internal wall surfaces of the fluid container, for example internal wall surfaces of a syringe barrel) or that remain in fluid conduction portions of such a fluid dispenser between the fluid container and a distal fluid ejection tip (e.g., remaining fluid in a dispensing needle). 
     The fluid container that contains the treatment composition may be part of a fluid dispenser. The fluid dispenser may be manipulable to dispense at least a portion of the treatment composition from the fluid container into the internal passage or through the internal passage directly into a paranasal sinus following implantation of the implant device. The fluid container may be provided in the kit by a syringe, which may be or be part of such a fluid dispenser. The fluid container may include at least a portion of a syringe barrel. A fluid dispenser may include a fluid ejection member in fluid communication with the treatment composition in the fluid container. Such a fluid ejection member may be insertable in the internal passage of the implant device, and the fluid dispenser may be manipulable when the fluid ejection member is inserted in the internal passage of the implant device when the implant device is implanted to eject at least a portion of the treatment composition from a distal end of the fluid ejection member into the internal passage of the implant device or distal of the distal internal passage directly into a paranasal sinus. For example, a distal fluid ejection tip of the fluid ejection member may be disposed in the internal passage and the treatment composition may be dispensed into the internal passage to then flow into the paranasal sinus, or the fluid ejection member may be inserted through the internal passage until the distal tip is disposed in the paranasal sinus distal of a distal end of the internal passage, and the treatment composition may be dispensed directly into the paranasal sinus. The fluid ejection member may be connected with a syringe, such as through a leur connection. The fluid ejection member may have an insertion portion configured to be inserted into the internal passage and such an insertion portion may have a maximum outside width (e.g., diameter) of no larger than 1.75 millimeters, no larger than 1.5 millimeters, no larger than 1.25 millimeters, no larger than 1 millimeter or no larger than 0.9 millimeter. The fluid ejection member may be or include a hollow needle having a blunt tip (e.g., blunt tip hypodermic needle). The fluid ejection member may be covered with a removable protective cap. For example, the kit may include a pre-filled syringe containing the treatment composition and fitted with a hypodermic needle that is covered with a protective cap that that protects the needle prior to use. A kit may include multiple different treatment compositions, and may include multiple fluid containers (e.g., multiple syringes) each containing a different treatment composition. 
     Forming a fistula for implantation of an implant device to provide a fluid passage between the lacrimal apparatus and a paranasal sinus involves making a hole through a wall of the bone in which the cavity of the paranasal sinus is located. As described herein, such a hole may be made by a sytlet or other solid piercing instrument and then widened as needed to form the fistula to the desired size for implantation of the implant device. For example following the initial piercing to make an initial hole, the hole may be dilated using dilators to make the hole progressively larger until the desired size is obtained. However, it has been found that when forming a fistula for implantation in such a manner, the bone tends to crack and shatter in the vicinity of hole. Although this does not present a medical problem, it has been found that if the bone is kept more in-tact in the vicinity of the hole, then the bone may provide mechanical support to help secure the implant device in place and prevent the implant device from migrating out of the fistula following implantation. Bone integrity in the vicinity of the fistula may be improved by cutting the hole for the fistula rather than piercing and dilating the hole. By cutting through the bone, rather than pushing through the bone, the bone remains more in-tact in the vicinity of the hole and provides better mechanical support to help retain the implant device in place in the fistula following implantation. The implantation kit of the second aspect may include tools useful for cutting a hole for a fistula and implanting an implant device. 
     A kit may include at least one cutting tool for cutting away tissue to form a fistula through which the implant device may be implanted during an implant procedure. Such a cutting tool may include a hollow member having a hollow cutting tip at a distal end of the cutting member configured to cut tissue to size the fistula for implantation of the implant device through the fistula. Such a cutting member may have a cutting width that is smaller than a maximum exterior width of a conduit of the implant device configured to be disposed through the fistula during implantation. Such a cutting tool may be a drill. 
     A kit may include a cutting tool that may be guidable by a guide member disposable through an internal passage of the cutting tool. The cutting tool may include a hollow cutting member that has a hollow cutting tip at a distal end of the cutting member configured to cut tissue to size the fistula for implantation of the implant device through the fistula. The hollow cutting tip of the cutting tool may be configured to make a larger diameter cut to enlarge a smaller-diameter preliminary cut that may have been previously made to accommodate the guide member, or the cutting tool may be configured to make a desired final cut without prior formation of a smaller initial fistula. The cutting member may be configured to be slidably engaged with the guide member with the guide member disposed through a passage in the cutting member with the distal end of the guide member disposed distal of the distal end of the cutting member. A distal end of the guide member may be configured to be disposed in or distal of the fistula such that the cutting member is slidable over the guide member, for example to conduct the cutting tip of the cutting member to cut tissue to size the fistula for implantation of the implant device when a smaller initial fistula has already been formed or to permit retraction of the cutting member while leaving the guide member in place for use to conduct another tool or tools to the location of the fistula, for example an implantation tool for inserting an implant device into the fistula in position for implantation following cutting a fistula of a desired size for implantation. 
     A cutting member of a cutting tool may be or include a hollow needle or a cutting cannula. The cutting member may have a cutting width, or diameter in the case of a circular cut, that is smaller than a maximum exterior width of the conduit of the implant device. The maximum exterior width of the conduit of the implant device may occur at one or more protrusion areas that form part of an anchoring surface feature on the conduit. The cutting width may be at least 0.1 millimeter smaller, at least 0.2 millimeter smaller, at least 0.25 millimeter smaller, at least 0.3 millimeter smaller, at least 0.35 millimeter smaller or at least 0.4 millimeter smaller than the maximum exterior width of the conduit of the implant device. The cutting width may be not more than 1 millimeter, 0.75 millimeter, 0.6 millimeter, or 0.5 millimeter smaller than the maximum exterior width of the conduit. The cutting width may be not larger than 5 millimeters, 4 millimeters, 3.5 millimeters, 3 millimeters, 2.5 millimeters, 2.25 millimeters, 2 millimeters, 1.9 millimeters or 1.8 millimeters. The cutting width may be at least 1 millimeter, 1.5 millimeter, 1.75 millimeter or 1.85 millimeter. 
     A kit may include an implantation guide tool with a proximal end and a distal end and including a guide member extending longitudinally in a direction from the proximal end toward the distal end of the implantation guide tool. The guide member and internal passage may be configured for mounting the implant device on the guide member with the guide member disposed through the internal passage of the implant device with a distal end of the guide member disposed distal of the distal end of the implant device, and the distal end of the guide member may be configured to be disposed in or distal of the fistula such that the implant device mounted on the guide member is slidable on the guide member toward the distal end of the guide member to conduct the implant device into the fistula for implantation. The guide member may be configured for insertion through a passage through a tool (e.g., cutting tool or carrier tool) to guide the tool to the site of a fistula. 
     In one example of a guide member, the guide member may be a guide wire or a small diameter needle (e.g., 20 gauge spinal needle), a cutting member may be a larger gauge needle through which the guide member may be inserted (e.g., 12 to 14 gauge spinal needle), and an implant device may have an internal passage through which the guide member may be inserted (e.g., 1 mm). 
     The guide member may be any appropriately sized member on which the implant device or a tool to be guided by the guide member may be slidably conducted along the guide member for implantation. The guide member may be a rigid, flexible or malleable material. The guide member may be a solid member, for example a solid guide wire or a stylet. The guide member may be a hollow member, for example the guide member may be or include a needle or cannula. The guide member may include a cutting end at the distal end configured to cut tissue to form at least a portion of the fistula. Such a hollow guide member with a cutting end may be a needle or cutting cannula. Such a hollow guide member with a cutting end may be useful to cut an initial hole that may then be made larger to a desired size for implantation of the implant device. 
     A kit may include a carrier tool, also referred to as an implantation tool, for carrying the implant device during an implantation procedure. Such a carrier tool may include a carrier member with a distal tip, with the carrier member being adapted to be disposed through a fistula between the lacrimal apparatus in the orbit and a paranasal cavity with the distal tip located in the paranasal cavity. The carrier tool may include a hand-manipulable handle connected to the carrier member. An implant device may be mountable on the carrier member for implantation of the implant device, with the mounted implant device disposed between the handle and the distal tip with the carrier member disposed through the internal passage and with a proximal end of the implant device disposed toward the handle and a distal end of the implant device disposed toward the distal tip of the member. When the implant device is mounted for implantation, the carrier member, and the carrier tool, may be disengageable from the implant device for implantation of the implant device during an implantation procedure to provide fluid access to a paranasal sinus. A clearance fit of the carrier member in the internal passage of the implant device when the implant device is mounted on the carrier member for implant placement may be small to ensure a close fit and help prevent lateral deformation of the implant device during implantation. For example such a clearance fit may be no larger than 0.5 millimeter, no larger than 0.4 millimeter, no larger than 0.3 millimeter, no larger than 0.2 millimeter or no larger than 0.1 millimeter. Having a close fit between of the carrier member in the internal passage of the implant device helps prevent accordion-like bunching of the implant device during an implant procedure as the carrier tool with the mounted device may be advanced to advance (push) the carrier member and the mounted implant device into the fistula for implantation. 
     Any and all parts of a kit may conveniently be contained within a common package, such as a common box, bag or other common packaging enclosure. Some or all components of a kit may be sterilized and sealed within hermetically sealed enclosures, such as for example hermetically sealed bags or wrapping. 
     A third aspect of the disclosure involves a method for performing a medical procedure in relation to a paranasal sinus and/or administering a treatment composition or performing a medical operation through an implanted implant device directed to the paranasal sinus. 
     A number of feature refinements and additional features are applicable to the third aspect of the disclosure. These feature refinements and additional features may be used individually or in any combination within the subject matter of the third aspect or any other aspect of the disclosure. As such, each of the following features may be, but are not required to be, used within any other feature or combination of features of the first aspect, the second, the third aspect or any other aspect of the disclosure. 
     A medical procedure of the method of a third aspect may include implanting an implant device to provide an artificial fluid path in fluid communication with the lacrimal apparatus. The method of the third aspect may involve cutting away tissue to form a fistula for implantation of an implant device, which is particularly advantageous when the fistula is to pass through bone, such as in the case of implant devices designed to provide an artificial fluid passage between the lacrimal apparatus and a paranasal sinus. The cutting away tissue may be to form a fistula of a size to receive at least a portion of a conduit of an implant device, the fistula having a proximal end opening into the lacrimal apparatus, and implanting the implant device with at least a portion of the conduit of the implant device in the fistula. Following the cutting away tissue, the method may include implanting an implant device to fluidly connect the lacrimal apparatus and the paranasal sinus. The implanting may include advancing the implant device into an implantation position using a carrier tool. The implanting may include advancing the carrier tool to have the carrier tool push the implant device into an implant position. The implanting may include sliding the implant device along a guide member or along a carrier member of a carrier tool into an implantation position. The implanting may include disengaging the carrier tool from the implant device positioned in the implant position. 
     In one variation, a method of the third aspect may comprise: 
     cutting away tissue to form a fistula having a proximal end opening into the lacrimal apparatus and a distal end opening into a paranasal sinus; 
     implanting an implant device to fluidly connect the lacrimal apparatus and the paranasal sinus, the implanting comprising: 
     advancing a carrier tool on which the implant device is mounted to push the conduit into the fistula from the proximal end of the fistula until the implant device is in an implantation position with a distal end of the conduit disposed in the paranasal sinus; and 
     disengaging the carrier tool from the implant device positioned in the implantation position. 
     In another variation, a method of the third aspect may comprise: 
     cutting away tissue to form a fistula of a size to receive at least a portion of a conduit of an implant device, the fistula having a proximal end opening into the lacrimal apparatus; 
     with a guide member having a distal end disposed in or distal of the fistula, sliding the implant device along the guide member toward the fistula; and 
     disposing at least a portion of the conduit of the implant device in the fistula. 
     A method procedure of the method of the third aspect may be or involve administering a treatment composition to a paranasal sinus through an implant device that fluidly connects the lacrimal apparatus with the paranasal sinus. 
     A method of the third aspect, or a portion thereof may be performed using a kit of the second aspect of this disclosure or parts of such a kit. When the method includes cutting away tissue, the cutting away tissue may comprise cutting the tissue with a cutting tool of such a kit. During the cutting away or some portion thereof, the cutting member may or may not be disposed over and conducted to the location for the cut by the guide member. For example, a preliminary cut may be made for form a preliminary hole of a smaller size, the guide member may be disposed with a distal end in or distal to the preliminary hole, and the cutting member may be slid over the guide member to cut tissue to produce a larger fistula of the desired size for implantation of the implant device. As another example, a single final cut may be made to make a hole of a final desired size for implantation which may be made without the aid of a guide member and without making a preliminary hole. In that regard, a shoulder on the ethmoid bone facing the orbit has been identified that is a convenient landmark for orienting a cut into the ethmoid sinus. The shoulder has been named the shoulder of Willoughby. When the method includes administering a treatment composition to a paranasal sinus the treatment composition may be as described in relation to the kit of the second aspect. 
     Cutting away tissue may be accomplished by removing tissue by drilling through the tissue with a drill, which drill may be provided in a kit of the second aspect. 
     The implant device for the third aspect (or for the second aspect) may include: 
     a proximal end and a distal end at opposite longitudinal ends of the implant device; 
     the conduit located between the proximal end and the distal end; 
     a first internal passage extending between the proximal end and the distal end of implant device and through the conduit, the first internal passage having a first end open at the proximal end of the implant device and a second end open at the distal end of the implant device; 
     a longitudinal length between the proximal end and the distal end of the implant device in a range of from 2 millimeters to 50 millimeters; 
     a width of the first internal passage transverse to the length in a range of from 0.25 millimeter to 5 millimeters; and 
     the implant device being configured to be implanted with the proximal end of the implant device disposed in the lacrimal apparatus. 
     The implant device for the third aspect may be an implant device of the first aspect of the disclosure or may include any feature or features described with respect to the first aspect of the disclosure, for example even if the implant device is not according to the first aspect. The implant device may as described with respect to the second aspect or may have any feature or features described in relation to the second aspect. 
     These and other aspects, and features thereof, are further described or will be apparent from the drawings and the description provided below. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       The drawings are included to aid in the understanding of various aspects of the disclosure and possible feature refinements and additional features applicable thereto. Features shown in the drawings are presented for purposes of illustration only, and are not necessarily to scale and are not necessarily detailed in every respect. 
         FIG. 1  is an illustration showing some example routes for an implant to provide fluid access from the lacrimal apparatus to a paranasal sinus. 
         FIG. 2  is perspective view of one embodiment of an implant device. 
         FIG. 3  is a side view of the same embodiment of an implant device as shown in  FIG. 2 . 
         FIG. 4  is an end view of the same embodiment of an implant device as show in  FIG. 2 . 
         FIG. 5  is a partial perspective view of the same embodiment of an implant device as shown in  FIG. 2 . 
         FIG. 6  is a partial side view of an embodiment of an implant device. 
         FIG. 7  is a partial side view of an embodiment of an implant device. 
         FIG. 8  is an illustration of cross-sections of various configurations for anchor protrusions for an implant device. 
         FIG. 9  is an illustration of various head configurations for an implant device. 
         FIG. 10  shows perspective, top, side and end views of an embodiment of an implant device. 
         FIG. 11  shows perspective, top, side and end view of an embodiment of an implant device showing some possible example dimensions. 
         FIG. 12  shows perspective, top, side and end views of an embodiment of an implant device. 
         FIG. 13  shows perspective, top, side and end view of an embodiment of an implant device showing some possible example dimensions. 
         FIG. 14  is an illustration showing an embodiment for placement of an implant device with a head of the implant device located within the orbit between the lacrimal caruncle and plica semilunaris. 
         FIG. 15  is an illustration showing use of a surgical tool, in the form of a cutting tool, to form a fistula between the orbit and an ethmoid sinus during a surgical procedure. 
         FIG. 16  is an illustration showing insertion of a guide wire following formation of a fistula during a surgical procedure. 
         FIG. 17  is an illustration showing a guide wire in place as a guide to a fistula during a surgical procedure. 
         FIG. 18  is an illustration showing use of a surgical tool, in the form of a carrier tool, for implantation of an implant device during a surgical procedure. 
         FIG. 19  is an illustration showing placement of an implant device following implantation during a surgical procedure. 
         FIG. 20  illustrates an embodiment of a kit useful for implanting a paranasal sinus access implant device and providing medical treatments using such a paranasal sinus access implant device. 
         FIG. 21  is a perspective view of an embodiment of an implant device. 
     
    
    
     DETAILED DESCRIPTION 
     The terms “lacrimal apparatus” and “lacrimal system” are used interchangeably herein to refer to the collection of physiological components that accomplish the production and secretion of lacrimal fluid to lubricate the eyeball, containment of lacrimal fluid in a reservoir of lacrimal fluid in the orbit and drainage of lacrimal fluid from the orbit to the nasal cavity. The lacrimal apparatus includes the lacrimal glands, the tear drainage system and the reservoir of lacrimal fluid located between the lacrimal glands and the tear drainage system. The reservoir of lacrimal fluid includes the eyelid margins and the conjunctival sac (and including the pool of tears in the lower conjunctival cul-de-sac that is sometimes referred to as the lacrimal lake). The tear drainage system includes the puncta, canaliculi and nasolacrimal duct (including the so-called lacrimal sac located at the top of the nasolacrimal duct) through which excess tears drain to Hasner&#39;s valve and into the nasal cavity.  FIG. 1  shows generally the lacrimal apparatus. Lacrimal fluid is produced and secreted from lacrimal glands  102  to lubricate the surface of the eyeball  104  disposed within the orbit. Lacrimal fluid forms a coating over the eyeball  104  and is generally contained within the conjunctival sac (the space between the lower eyelid  106 , upper eyelid  108  and eyeball  104  that is lined by the conjunctiva). Excess lacrimal fluid is conducted to the vicinity of the medial canthus (medial corner of the eye) and drains through the lacrimal puncta  110  into the lacrimal canaliculi  112  and into the lacrimal sac  114  of the nasolacrimal duct  116 . The lacrimal fluid then drains from the nasolacrimal duct  116  through Hasner&#39;s valve and into the nasal cavity. 
     As used herein, a fistula between the lacrimal apparatus and a paranasal sinus refers to an artificially-created passage that fluidly connects the lacrimal apparatus with a paranasal sinus. Such a fistula may be surgically created. The paranasal sinuses include the frontal sinuses, maxillary sinuses, ethmoid sinuses and sphenoid sinuses, which are cavities contained within frontal, maxilla, ethmoid and sphenoid bones, respectively. The paranasal sinuses drain into the nasal cavity.  FIG. 1  also shows the general proximity of the frontal sinus  122 , maxillary sinus  124  and ethmoid sinus  126  relative to features of the lacrimal apparatus and some example fistula routes shown by dashed lines. A first example fistula route  130  is from the orbit to the frontal sinus. A second example fistula route  132  is from the orbit to the ethmoid sinus  126 . A third example fistula route  134  is from the orbit to the maxillary sinus  124 . A fourth example fistula route  136  is from the lacrimal sac  114  at the top of the nasolacrimal duct  116  to the ethmoid sinus  126 . A fifth example fistula route  138  is from the nasolacrimal duct  116  at a location below the lacrimal sac  114  to the ethmoid sinus  126 . A sixth example fistula route  140  is from the nasolacrimal duct  116  at a location below the lacrimal sac  114  to the maxillary sinus  124 . The example fistula routes shown in  FIG. 1  are for purposes of general illustration only and not to show precise locations where a fistula might be formed to connect a part of the lacrimal apparatus with the corresponding paranasal sinus. Although not shown in  FIG. 1 , example fistula routes to the sphenoid sinus include from the orbit to the sphenoid sinus and from the nasolacrimal duct  116  to the sphenoid sinus. 
       FIGS. 2-5  show one embodiment of an implant device, for example that may be implanted through a fistula at the first, second or third routes  130 ,  132 , or  134  shown in  FIG. 1 . As shown in  FIGS. 2-5 , an implant device  200  has a proximal end  202  and a distal end  204  located on opposite longitudinal ends of the implant device  200 . The implant device  200  includes a head  206  at the proximal end  202  and a conduit  208  extending from the head  206  to the distal end  204 . An internal passage  210  extends from the proximal end  202  to the distal end  204 , passing through the head  206  and the conduit  208 . The internal passage  210  opens at the proximal end  202  and the distal end  204 , thereby providing a passage through the entire longitudinal length of the implant device  200 . The internal passage  210  of the embodiment shown in  FIG. 2  has a cylindrical shape with a uniform circular cross-section (transverse to the length of the implant device  200 ), and the width of the internal passage is equal to the diameter of the circle of the cross-section and is uniform along the length of the implant device  200 . The length of the implant device  200  is the minimum distance longitudinally along the implant device  200  between the proximal end  202  and the distal end  204 , and will typically be equal to the distance along an axis of the internal passage  210  from the proximal end  202  to the distal end  204 . The implant device  200  includes multiple anchor protrusions  212  on an exterior of the conduit  208 . In the embodiment shown in  FIGS. 2-5 , the anchor protrusions  212  are in the form of spaced circumferential ridges that each extends around the entire circumference of the conduit  208 . Adjacent the circumferential ridges of the anchor protrusions  212  are areas of recess  214  on the exterior of the conduit  208 . 
     The head  206  has a flanged tissue engagement surface  216  on a side of the head  206  disposed toward the conduit  208 , and which flanged tissue engagement surface  216  is advantageously configured to engage tissue adjacent the proximal end of fistula and to prevent the proximal end  202  of the implant device  200  from migrating into the fistula following implantation. On the side of the head  206  opposite the flanged tissue engagement surface  216  is a face surface  218  of the head  206 , which face surface  218  is disposed away from tissue engaged by the flanged tissue engagement surface  216  when the implant device is implanted. The head  206  has a first dimension  220  and a second dimension  222  on both the flanged tissue engagement surface  216  and the face surface  218 . The first dimension  220  is the length of the respective surface and the second dimension is the width of the respective surface. Such length and width dimensions may also be referred to as major and minor dimensions. The first dimension  220  of a surface  216  or  218  corresponds to the maximum separation distance between points on the outer edge of the surface (maximum cross dimension across the head), and the second dimension  222  of the surface  216  or  218  corresponds to the maximum separation distance between points on the outer edge of the surface that are on a line transverse (perpendicular) to the first dimension. Conveniently, the face surface  218  and the flanged tissue engagement surface  216  may be made with corresponding outer edges, so that the opposing surfaces  216  and  218  have substantially equal length and width dimensions, although such is not required. The first dimension  220  and the second dimension  222  may be referred to generally as the length and width, respectively, of the head  206  when the surfaces  216  and  218  have corresponding shapes, as is the case for the embodiment shown in  FIGS. 2-5 . When the surfaces  216  and  218  do not have corresponding shapes, the length and width dimensions of the head will be different from one or more of the length and width dimensions of the surfaces  216  and  218 . The head  206  has a depth dimension  223  between surfaces  216  and  218 . 
     With continued reference to  FIGS. 2-5 , the conduit  208  has a first exterior width  224  that is a maximum exterior width of the conduit  208  as defined by the maximum extents of the anchor protrusions  212  transverse to the length of the conduit  208 . The conduit  208  has a second exterior width  226  that is a minimum exterior width of the conduit  208  defined between the most recessed portions of the areas of recess  214 . In the embodiment shown in  FIGS. 2-5 , the height of the anchor protrusions  212  is equal to one-half the difference between the first exterior width  224  and the second exterior width  226  of the conduit  208 . In the configuration of the head  206  shown in  FIGS. 2-5 , the first dimension  220  of the head is larger than both the first exterior width  224  and the second exterior width  226  of the conduit  208 , while the second dimension  222  of the head is approximately equal to the second exterior width  224  of the conduit  208 . 
     With continued reference to  FIGS. 2-5 , the anchor protrusions  212  are in the form of spaced circumferential ridges having a width that is at a maximum at the bottom of the ridges located adjacent the areas of recess  214 , and which width tapers to a minimum at the top of the ridges  212  located away from the recess areas  214 . Other configurations for anchor protrusions are possible, and all anchor protrusions on an implant device need not be of the same size, geometry or height. Likewise, areas of recess may have varying configurations, and not all recesses on an implant device need to be the same size or configuration. The implant device  200  has a length  228  including the depth  223  of the head  206  and the length of the conduit  208 . The anchor protrusions  212  are on a longitudinal portion  230  of the conduit  208 . 
     Referring now to  FIG. 6 , an alternative embodiment is shown of a conduit  240  of an implant device having anchor protrusions  242  in the form of knobs, or buttons, and areas of recess  244  adjacent the anchor protrusions  242 . The conduit  240  has a first exterior width  246  defined by the anchor protrusions  242  and a smaller, second exterior width  248  defined by the areas of recess  244 . An example of another configuration for anchor protrusions is shown in  FIG. 7 . As shown in  FIG. 7 , a conduit  250  of an implant device has anchor protrusions  252  and areas of recess  254  on the exterior surface of the conduit  250 . The anchor protrusions  252  are in the form of a continuous spiral ridge extending along a portion of the longitudinal length of the conduit  250 . The conduit  250  has a first exterior width  256  defined by the anchor protrusions  254  and a smaller, second exterior width  258  defined by the areas of recess  254 . As with the embodiments shown in  FIGS. 2-5 , the conduit embodiments shown in  FIGS. 6 and 7  include a height of the anchor protrusions that is equal to one half the difference between the larger and smaller outer diameters of the respective conduits. As will be appreciated from the embodiments of  FIGS. 6 and 7 , the first exterior width is determined as the width of an envelope volume that contains the anchor protrusions. 
       FIG. 8  shows examples of some shapes for anchor protrusions that include a tapering width in a direction from the base of the anchor protrusion toward a top of the anchor protrusion.  FIG. 8  shows cross-sections of anchor protrusion configurations (designated A-D), each having a greater width at the base than at the top. The height (H) and base width (W) of the anchor protrusions are indicated in  FIG. 8 . 
       FIG. 9  shows some different example configurations (designated E-H) for a head for an implant device. For each head configuration, the length dimension (L) and width dimension (W) of the head configurations are shown. The heads of configurations E-H are shown on end showing the face surface (surface facing away from the fistula when implanted) and the opening of the internal passage at the proximal end of the implant device. Configurations F-H, with a larger length than width, are advantageously configured for use with fistulas opening into the orbit between the medial canthus and the medial side of the adjacent eyeball, for example between the plica semilunaris and the lacrimal caruncle, and preferably with the length dimension of the head extending generally in a direction from the bottom of the orbit toward the top of the orbit next to the eyeball, and for configuration H with the concave side of the crescent disposed toward the eyeball and the convex side of the crescent disposed towards the lacrimal caruncle. 
       FIG. 10  shows an implant device  700  with a head  702  and a conduit  704 . The conduit  704  includes a first longitudinal portion  706  and a second longitudinal portion  708  disposed distal of the first longitudinal portion  706 . The first longitudinal portion  706  includes a smooth exterior surface and the second longitudinal portion  708  includes an anchoring surface feature including anchor protrusions  710 , in the form of spaced circumferential ridges, and recess areas  712  between the anchor protrusions  710 . The length of the first longitudinal portion  706  located before the beginning of the anchoring surface feature of the second longitudinal portion  708  may advantageously be disposed in conjunctival tissue adjacent the head  702  when implanted to “float” for patient comfort. The anchoring features of the second longitudinal portion  708  may advantageously be located a distance from the head  702  so that one or more of the anchor protrusions  710  are located in the vicinity of the paranasal sinus bone wall that is penetrated by the implant device  700  when implanted, preferably with one or more of the anchor protrusions disposed on each side of the bone. In the embodiment shown in  FIG. 10 , the exterior width of the conduit  704  is substantially the same for the whole length of the first longitudinal portion  706  and in the recess areas  712  of the second longitudinal portion  708 . The conduit  704  has a circular cross-section, so that the exterior width of the conduit  704  at any location along the conduit  704  is represented by the diameter of the circular cross-section of the conduit  704  at that location. As shown in  FIG. 10 , the implant device  700  has a length  714  from a proximal end  716  to a distal end  718  of the implant device  700 . The beginning of the second longitudinal portion  708  is located a distance  720  distal from the proximal end  716 . The anchor protrusions  710  have a width  722  at the base of the anchor protrusions  722  and a height  724  above the adjacent recess areas  712 . The anchor protrusions  710  are spaced on a center-to-center spacing  726 . The conduit  704  has a maximum exterior width  728  corresponding with the tops of the anchor protrusions  710 , equal to the diameter of the circle of the cross-section through the conduit  704  at the top of the anchor protrusions  710 . The conduit  704  has a minimum exterior width  730  along the length of the first longitudinal portion  706  and in the recess areas  712  of the second longitudinal portion  708  of the conduit  704 , and which is equal to the diameter of the circular cross-section at those locations. The head  702  has a length dimension  732 , a width dimension  734  and a depth dimension  736 . The implant device  700  has an internal passage  738  extending between the proximal end  716  and the distal end  718  and through the length of the conduit  704 . The internal passage  738  has a width  740 , which in this embodiment is equal to a diameter of the circular cross-section of the internal passage  738 .  FIG. 11  shows the same implant device  700  as shown in  FIG. 10  with some exemplary dimensions, in millimeters, for one nonlimiting example for a configuration for the implant device  702 . 
       FIG. 12  shows an implant device  800  that is similar to the implant device  700  shown in  FIGS. 10 and 11 , except including a first longitudinal portion of a conduit having a thicker wall than recess areas of the anchoring surface feature of a second longitudinal portion of the conduit. The thicker wall in the first longitudinal portion of the conduit provides added rigidity to that portion of the conduit to facilitate pushing the implant device  800  into place during an implantation procedure, while the thinner wall in the recess areas of the second longitudinal portion of the conduit permit that portion to more easily deform and fit through a fistula during implantation and then to expand to engage tissue and anchor the implant device  800 . More specifically as shown in  FIG. 12 , the implant device  800  includes a head  802  and a conduit  804 . The conduit  804  has a first longitudinal portion  806  and a second longitudinal portion  808  located distal of the first longitudinal portion  806 . The first longitudinal portion  806  includes a substantially smooth exterior surface with a substantially constant exterior width, which is the diameter of the circular cross-section of the conduit  804  along the first longitudinal portion  806 . The second longitudinal portion  808  includes an anchoring surface feature including anchor protrusions  810 , in the form of circumferential ridges, and recess areas  812  in the spaces between the anchor protrusions  810 . Various dimensions of the implant device  802  are illustrated in  FIG. 12 , similar to the illustration provided for the implant device  700  in  FIG. 10 . The implant device  800  has a length  814  from a proximal end  816  to a distal end  818  of the implant device  800 . The beginning of the second longitudinal portion  808  is located a distance  820  distal of the proximal end  816 . The anchor protrusions have a width  822  at the base and a height  824  above the adjacent recess areas  812 . The anchor protrusions are spaced on a center-to-center spacing  826 . The conduit  804 , and also the second longitudinal portion  808 , has a maximum exterior width  828  occurring at the tops of the anchor protrusions  810 , and equal to the diameter of the circular cross-section of the conduit  804  through the tops of the anchor protrusions  810 . The conduit  804 , and the second longitudinal portion  808 , of the conduit  804  have a minimum exterior width  830  located at the recess areas  812 . The head  802  has a length dimension  832 , a width dimension  834  and a depth dimension  836 . The implant device  800  has an internal passage  838  extending between the proximal end  816  and the distal end  818  and through the length of the conduit  804 . The internal passage  838  has a width  840 , which in the embodiment shown in  FIG. 12  is equal to a diameter of the circular cross-section of the internal passage  838 . 
     With continued reference to  FIG. 12 , the wall thickness of the conduit  804 , (thickness of the wall between the internal passage  838  and the exterior surface of the conduit  804 ) is greater along the first longitudinal portion  806  than in the recess areas  812  of the second longitudinal portion  808 . The internal passage  838  has a constant width along the length of the conduit  804 , such that the greater wall thickness of the conduit  804  along the first longitudinal portion  806  results in an exterior width  842  that is larger than the minimum exterior width  830  in the recess areas  812 . The maximum exterior width  828  at the anchor protrusions  810  is larger than the exterior width  842  along the first longitudinal portion  806 .  FIG. 13  shows some exemplary dimensions, in millimeters, for one nonlimiting example for a configuration of the implant device  800 . 
       FIG. 21  shows a variation on the implant device  800  of  FIG. 20 . The implant device  800 ′ of  FIG. 21  has the same features as the implant device  800  of  FIG. 20 , except that the implant device  800 ′ includes a plurality of side openings  850  (which may also be referred to as holes, apertures or ports) through the wall of a distal portion of the conduit  804 ′. The side openings  850  may be located on a portion of the conduit wall that would be disposed in the paranasal sinus when the implant device  800 ′ is implanted, such that the side openings  850  may provide a passage for fluid communication between the internal passage of the implant device  800 ′ and the paranasal sinus even if the distal opening of the internal passage at the distal end of the conduit  804 ′ were to become blocked or restricted for some reason. In the particular implementation shown in  FIG. 21 , the implant device  800 ′ the side openings  850  are located in a recess area between a pair of circumferential ridges of an anchoring surface feature of the conduit  804 ′.  FIG. 21  shows the side openings  850  located in only one recess area between one pair of circumferential ridges, but one or more similar side openings could also or alternatively be located in a more proximal recess area between a different pair of the circumferential ridges. 
       FIG. 14  shows an example of an implant device with a conduit passing through a fistula formed from the orbit subconjunctivally between the lacrimal caruncle  142  and the plica semilunaris  144 , and showing an example location for the head  304  of the implant device disposed in the orbit between the lacrimal caruncle  142  and the plica semilunaris  144 . The head  304  is shown with an elongated configuration, such as for example a head configuration shown in any of  FIGS. 2-5 ,  FIGS. 10-13 , or configurations F-H shown in  FIG. 11 . 
     Referring now to  FIGS. 15-18 , some examples of surgical procedures involving forming a fistula and implanting an implant device to provide access to a paranasal sinus, and some example surgical tools for use therewith, will now be described. 
     In  FIG. 15  a surgical tool, in the form of an entry tool  600  is shown in the process of making a fistula through tissue between the lacrimal caruncle  142  and the plica semilunaris  144 . Numbering of anatomical parts is the same as in  FIG. 1 . The fistula is formed through tissue between the conjunctival sac in the orbit and the ethmoid sinus  126 . The route for the fistula would be consistent with general fistula route  132  as shown in  FIG. 1 . The entry tool  600  includes a hollow working member  606  with a hollow cutting distal tip  610  with a shape suitable to cut away tissue to form a fistula from the conjunctival sac to the ethmoid sinus  126 . The entry tool  600  may also be referred to as a cutting tool and the working member may also be referred to as a cutting member. The entry tool  600  includes a hand-manipulable handle  612 . The handle  612  may be advanced or retracted to advance or retract the hollow working member  606 . As shown in  FIG. 15 , the distal cutting tip  610  has been advanced from a location in the conjunctival sac between the caruncle  142  and the plica semilunaris  144  to form a fistula between the conjunctival sac and the ethmoid sinus  126 . As shown, the fistula passes behind the caruncle  142 , canaliculi  112  and nasolacrimal duct  116  to access the ethmoid sinus  126 . 
     After the entry tool  600  has been used to initially form a fistula to the ethmoid sinus  126 , then a guide wire or other guide member may be inserted through an internal passage extending through the handle  612  and the hollow working member  606 .  FIG. 16  shows a guide wire  620  inserted through the handle  612  and the working member  606 . After insertion of the guide wire  620 , entry tool  600  may be retracted and removed from the fistula, leaving the guide wire  620  in place as a guide to and through the fistula, as shown in  FIG. 17 . The guide wire  620  is now available for guiding additional tools to and through the fistula into the ethmoid sinus  126 . 
     With reference now to  FIG. 18 , the guide wire  620  has been used to guide a surgical tool, in the form of an implant tool  624 . The implant tool may also be referred to as a carrier tool. The implant tool  624  includes a hollow working member  626  and a hand-manipulable handle  628 . The working member  626  may have a blunt distal tip, as shown in  FIG. 18 , since the working member  626  may not need to cut additional tissue following formation of the fistula using the entry tool  600 , provided that the fistula has already been formed to a final desired size. The working member  626  may also be referred to as a carrier member. The implant tool  624  includes an internal passage passing through the handle  628  and the hollow working member  626 . As shown in  FIG. 18 , the guide wire  620  has been threaded through the internal passage of the implant tool  624  to guide the hollow working member  626  to and through the fistula and into the ethmoid sinus  126 . An implant device  630  is mounted on the hollow working member  626  of the implant tool  624 .  FIG. 18  shows the implant tool  624  advanced to a point where the distal end of the implant device  630  is in the vicinity of the proximal end of the fistula opening into the conjunctival sac. From this position, the implant device  630  may be advanced into the fistula with a head of the implant device  630  disposed adjacent the conjunctiva in the conjunctival sac and a distal end of the implant device  630  extending into the ethmoid sinus  626 . For example, a surgeon may slide the implant device  630  down the hollow working member  626  for placement through the fistula for implantation or the surgeon may advance the handle  628  to have the handle push the implant device  630  into the fistula for implant placement. The outside diameter of the hollow working member  626  may be sized to closely fit within the inside diameter of the implant device  630  to help prevent the implant device  630  from bunching-up and laterally deforming as the implant device is pushed into the fistula. The handle  628  and the hollow working member  626  form a carrier for the implant device  630 . The handle  628  may be retracted and the hollow working member  626  disengaged from the implant device  630  after the implant device  630  has been appropriately positioned for implantation through the fistula.  FIG. 19  shows the implant device  630  as implanted and following disengagement of the hollow working member  626  of the implant tool  624 . As implanted, a head  632  at the proximal end of the implant device  630  is located adjacent the conjunctiva in the conjunctival sac within the orbit between the caruncle  142  and the plica semilunaris  144  and the distal end  634  of the implant device  630  is located in the ethmoid sinus  126 . Some anchor protrusions  636  of the conduit of the implant device  630  are disposed within the fistula to engage tissue and help anchor the implant device  630 . The implant device  630  may be used to provide access to the ethmoid sinus  126  to perform medical procedures or treatments, for example to administer a treatment composition to the ethmoid sinus or to aspirate fluid from the ethmoid sinus. 
     The procedure as described with reference to  FIGS. 15-19  permits the working member  606  of the entry tool  600  to have a larger diameter working member  626  to form a fistula of appropriate size for accommodating the implant device  630  which is then implanted in a separate step using the implant tool  624  with the implant device  630  carried on to the working member  626 , which may advantageously have a smaller diameter than the working member  606  used to form the fistula. As an alternative, an intermediate step to dilate the fistula or to cut away additional tissue to a desired hole size for implantation may be performed between initially forming a fistula with the entry tool  600  and implanting the implant device  630  using the implant tool  624 . 
     Referring again to  FIG. 15 , optionally, one or more procedures may be performed prior to retracting the hollow working member  606 . One or more fluids may be injected through the hollow working member  606 . For example, contrast media may be injected through the hollowing working member  612  and may be imaged to confirm that the fistula has been formed to the proper location prior to proceeding with implantation. 
     The cutting may be performed, for example, with a cutting tool such as a needle or cannula that cuts tissue or a drill that drills out the tissue. A method may include cutting an initial hole at the location of the desired fistula, and then using a guide member and further tools to complete an implantation procedure. For example, the initial cut may be to make a preliminary hole and a larger gauge needle or cutting cannula may be guided by the guide member to cut the fistula to the final desired size for implantation of the implant device. Alternatively, the initial hole that is cut may be of a final desired size for implantation of the implant device. After the hole has been made to the desired size, the guide member may then be used to guide the implant device or a carrier tool on which the implant device is mounted to the fistula for implantation of the implant device. As one example, a small gauge needle may be used to form an initial cut, and a guide wire may then be inserted through the needle and into the fistula to maintain control of the fistula. The smaller gauge needle may then be retracted and the second cutting tool, in the form of a larger gauge needle, may be slid over the guide wire and conducted to the proper location to cut the fistula to the proper size for implantation of the implant device. A kit for performing such an operation my include the implant device, the smaller gauge needle, the guide wire (as the guide member) and the larger gauge needle as the cutting tool for making the fistula to the final desired size. As another example, the initial cutting tool, or a portion thereof may be used as the guide member for the subsequent cutting tool. For example, the initial cut may be made using a smaller gauge needle having a handle, such as a spinal needle or similar design. Following the initial cut, the handle, or head, may be cut off and removed from the smaller gauge needle and a cutting tool in the form of a larger gauge needle may then be slid over the smaller gauge needle to cut the hole to the final desired size for the fistula. The larger gauge needle may then be retracted and the implant device may be slid over the smaller gauge needle and conducted to the proper location for implantation. A kit for performing such an operation may include the implant device, the smaller gauge needle (which serves as the guide member) and the larger gauge needle as the cutting tool for making the fistula to the final desired size. Alternatively, a kit may include a single cutting tool (e.g., hollow needle or cutting cannula) sized to cut a hole of the final desired size through which the implant device is to be implanted, and without enlargement by further cutting or dilation. 
     Referring now to  FIG. 20 , an example embodiment of a kit is shown that includes components for implanting a paranasal access implant device and delivering a treatment composition to a paranasal sinus through the implant device. As shown in  FIG. 20 , a kit  968  includes a paranasal sinus access implant device  970 . The implant device  970  may for example have any design according to or with features shown or described in relation to any of  FIGS. 2-13 , or may have a different design. The kit also includes a paranasal sinus fluid manipulation tool  972 , which includes a fluid dispenser in the form of a syringe  974  and a fluid transmission attachment  976  including a fluid ejection member  977  in the form of a blunt tip hollow needle. The fluid transmission attachment  976  includes an engagement structure at a distal end to engage with a head on a proximal end of the implant device  970  to facilitate transmission of fluid from inside a barrel of the syringe  974  to be ejected from a distal tip of the fluid ejection member  977 . The syringe  974  includes a piston  978  disposed in the barrel of the syringe  974  and that is hand manipulable by advancement or retraction of a plunger  980  to move the piston  978  in the syringe barrel to create pressure to expel fluid from the syringe barrel through the fluid transmission attachment  976  or to create a vacuum to suction fluid through the fluid transmission attachment  976  into the syringe barrel. The fluid manipulation tool  972  may be provided with the syringe  974  and the fluid transmission attachment  976  assembled as shown in  FIG. 20 , or may be provided with the syringe  974  and the fluid transmission attachment  976  as separate, disassembled pieces that are assemblable into the assembly as shown in  FIG. 20 . In some preferred implementations, the syringe  974  may be prefilled with a treatment composition disposed inside the barrel of the syringe  974 . Such a prefilled syringe  974  may be provided in the kit  968  assembled with the fluid transmission attachment  976  as shown in  FIG. 20 , and preferably with a protective cap covering the fluid transmission attachment  976 , and which cap is removable by a medical practitioner for use of the fluid manipulation tool  972  to administer a treatment composition to a patient in which the implant device  970  has been implanted to provide access to a paranasal sinus. A treatment composition disposed in the barrel of the syringe  974  may be an irrigation liquid or a drug composition, for example as previously described. 
     The kit  968  as shown in  FIG. 20  also includes tools for forming a fistula between the lacrimal apparatus in the orbit and a paranasal sinus, for example a frontal, maxillary or ethmoid sinus. As shown in  FIG. 20 , the kit  968  includes a cutting tool  982  having a hollow cutting member  984  (e.g., hollow needle) for cutting away tissue to form a fistula of a size suitable for implantation of the implant device  972  without enlargement by further cutting or dilation. Alternatively a kit could include a cutting tool with a smaller gauge cutting member or piercing member to form an initial hole and one or more additional tools (e.g., cutting tool with larger gauge cutting member and/or dilator) may be included in a kit to enlarge the initial hole to a final desired size for implantation. The cutting tool  982  may for example have a design according to or including features as shown or described in relation to either of  FIGS. 15 and 16 , or may be of a different design. 
     The kit  968  as shown in  FIG. 20  also includes a carrier tool  986  having an carrier member  988 , which has an outside diameter sized for insertion of the carrier member  988  through the internal passage of the implant device  970  to mount the implant device  970  on the carrier member  988  to carry the implant device  970  for implantation after a fistula has been formed to a desired size. The carrier tool  986  may for example have a design according to or including any features as shown in or described in relation to  FIG. 18  or may be of a different design. The carrier tool  986  and the implant device  970  may be provided in the kit  968  as separate, assemblable pieces such as is shown in  FIG. 20 . Alternatively, the carrier tool  986  and the implant device  970  may be provided in the kit with the implant device  970  pre-mounted on the carrier member  988  in a configuration ready for use in an implantation procedure. 
     The fluid ejection member  977  is configured to be inserted into an internal passage that extends through the implant device  970 . After implantation of the implant device  970  to provide access to a paranasal sinus, the fluid ejection member  977  may be inserted into the internal passage from the proximal end of the implant device  970  that is disposed in the orbit following implantation. After insertion of the fluid ejection member  977  into the internal passage of the implant device  970 , the plunger  980  may be pushed to advance the piston  978  to force treatment composition in the barrel of the syringe  974  to flow to and be ejected from the distal tip of the fluid ejection member  977 . The fluid ejection member  977  may be inserted into the internal passage of the implant device  970  so that the distal tip of the fluid ejection member  977  is disposed in the internal passage when the treatment composition is ejected and the treatment composition is ejected into the internal passage from which the treatment composition may flow to the paranasal sinus. Alternatively, the injection member  977  may be inserted into the internal passage of the implant device  970  until the distal end of the injection member exits a distal end of the internal passage into the paranasal sinus, in which case the treatment composition may be ejected from the fluid ejection member  977  directly into the paranasal sinus. 
     The cutting tool  982  and the carrier tool  986  may have internal passages therethrough for insertion of a guide member (e.g., a guide wire). A kit may include such a guide wire or other guide member. 
     A variety of medical treatments and procedures may be performed through a paranasal sinus access implant device implanted to provide access to a paranasal sinus. Fluid treatment compositions may be administered to a paranasal sinus through the implant device. Fluid may be aspirated from a paranasal sinus through the implant device. One or more medical devices may be inserted into the paranasal sinus through the implant device. 
     The foregoing discussion of the invention and different aspects thereof has been presented for purposes of illustration and description. The foregoing is not intended to limit the invention to only the form or forms specifically disclosed herein. Consequently, variations and modifications commensurate with the above teachings, and the skill or knowledge of the relevant art, are within the scope of the present invention. The embodiments described hereinabove are further intended to explain best modes known for practicing the invention and to enable others skilled in the art to utilize the invention in such, or other, embodiments and with various modifications required by the particular applications or uses of the present invention. It is intended that the appended claims be construed to include alternative embodiments to the extent permitted by the prior art. Although the description of the invention has included description of one or more possible implementations and certain variations and modifications, other variations and modifications are within the scope of the invention, e.g., as may be within the skill and knowledge of those in the art after understanding the present disclosure. It is intended to obtain rights which include alternative embodiments to the extent permitted, including alternate, interchangeable and/or equivalent structures, functions, ranges or steps to those claimed, whether or not such alternate, interchangeable and/or equivalent structures, functions, ranges or steps are disclosed herein, and without intending to publicly dedicate any patentable subject matter. Furthermore, any feature described or claimed with respect to any disclosed implementation may be combined in any combination with one or more of any other features of any other implementation or implementations, to the extent that the features are not necessarily technically incompatible, and all such combinations are within the scope of the present invention. 
     The terms “comprising”, “containing”, “including” and “having”, and grammatical variations of those terms, are intended to be inclusive and nonlimiting in that the use of such terms indicates the presence of some condition or feature, but not to the exclusion of the presence also of any other condition or feature. The use of the terms “comprising”, “containing”, “including” and “having”, and grammatical variations of those terms in referring to the presence of one or more components, subcomponents or materials, also include and is intended to disclose the more specific embodiments in which the term “comprising”, “containing”, “including” or “having” (or the variation of such term) as the case may be, is replaced by any of the narrower terms “consisting essentially of” or “consisting of” or “consisting of only” (or the appropriate grammatical variation of such narrower terms). For example, a statement that some thing “comprises” a stated element or elements is also intended to include and disclose the more specific narrower embodiments of the thing “consisting essentially of” the stated element or elements, and the thing “consisting of” the stated element or elements. Examples of various features have been provided for purposes of illustration, and the terms “example”, “for example” and the like indicate illustrative examples that are not limiting and are not to be construed or interpreted as limiting a feature or features to any particular example. The term “at least” followed by a number (e.g., “at least one”) means that number or more than that number. The term “at least a portion” means all or a portion that is less than all. The term “at least a part” means all or a part that is less than all. 
     The features in the drawings are shown for illustration purposes and to generally show relative positioning and interaction, and the features shown are not necessarily to scale.