Patent Description:
The disclosure contained herein utilize therapeutic sound or ultrasound i. Sound and ultrasound are also contained in the broad category of mechanical vibration.

Description of the Background Art. A device to create tearing to treat dry eye has recently been developed (<CIT>) which utilizes an intranasal neurostimulator to activate nerves in the nasal mucosa. This device is placed inside the nostrils and two prongs grab onto the septum after which electrical current is applied across the septum. According to the company and research in the field, the electrical stimulation activates the interior branch of the anterior ethmoidal nerve. Within a few minutes, tears are generated. A randomized showed that the device, when placed intranasally, compared to sham, was highly effective in producing tears (product brochure; www. com), tears which contain the typical concentration of proteins and glycoproteins. The sham procedure was one in which the same neurostimulation device and parameters were applied to the skin on the outer nostril. The sham procedure on the outer skin of the nostril did not change the baseline amount of tearing from baseline and served as an outstanding control. The intranasal neurostimulator was uncomfortable for many patients and resulted in a great number of side effects including an epistaxis rate of over <NUM> percent. Most patients also reported that they would not perform the procedure in public although their symptoms were dramatically improved.

Another dry eye treatment involves a procedure in which a lens is placed over the cornea and a device then compresses the eyelid between the device and the cornea, applying both pressure and heat (e.g. <CIT>, www. tearscience. The procedure is performed in an ophthalmologist office and the device has been shown to open the glands on the inside of the eye, called Meibomian Glands (and the disease is called Meibomian Gland Disease or MGD). This device also had been shown to be effective for dry eye in clinical trials but is also cumbersome and expensive for an ophthalmologist and patients, lasting about <NUM> to an hour inside a physician's office. See also <CIT>; <CIT>; <CIT>;and <CIT>.

While these devices represent advances in the treatment of dry-eye, new methods and devices are needed to treat dry eye and associated lack of ability to produce tears and maintain sufficient Meibomian gland secretions. The devices should also be designed with a low cost and form factor which encourages compliance and facilitates their utilization. At least some of these advantages will be met by the disclosure herein.

<CIT> discloses an applicator which includes a housing and a motor contained therewithin which includes an output member, such as a shaft, which in operation moves in a reciprocating manner. A contact member is mounted for operation and moves in response to the action of the output shaft, such that the contact element in operation repeatedly contacts a selected skin area, moving toward and away from the skin area, substantially perpendicularly thereto. The contact member moves at a frequency within the range of <NUM> to <NUM> and with an amplitude of <NUM> to <NUM> inches (<NUM> to <NUM>). The repeated tapping action of the contact member against the skin increases the absorption of a skin formulation into the skin area being contacted.

<CIT> describes a method of treating meibomian gland dysfunction. The method includes directing RF energy to an internal portion of a meibomian gland, selectively targeting an obstruction within a duct of the meibomian gland with the applied RF energy to melt, loosen, or soften the obstruction, and expressing the obstruction from the duct of the meibomian gland. An apparatus for treating meibomian gland dysfunction is also disclosed. The apparatus comprises at least one RF electrode configured to direct RF energy to an internal portion of a meibomian gland located in an eyelid of an eye, the at least one RF electrode further configured to selectively target an obstruction within a duct of the meibomian gland with the applied RF energy to melt, loosen, or soften the obstruction. The apparatus also comprises at least one expressor configured to express the obstruction from the duct of the meibomian gland. One embodiment discloses a hand held apparatus comprising a power source residing within a housing. The power source provides electrical current to a wave form generator which powers an acoustic amplifier (for example, a small audio speaker) also located within housing and mounted at an ergonomic angle therein. The acoustic amplifier is programmed to vibrate in a wave format at a frequency of <NUM> to <NUM> at an amplitude in the range of <NUM> to <NUM>, <NUM> to <NUM>, or <NUM> to <NUM>. The end of the housing is adapted to mount a variety of tips.

<CIT> describes a method of and device for treating nasal congestion and/or relieving sinusitis symptoms in a patient, comprising attaching a vibration generating means to the patient head, at a location adjacent to sinuses to be treated, generating a vibration by said vibration generating means, and delivering the same to said patient.

<CIT> describes an electrically-driven magnet cosmetic massager consisting of: a main body with a battery-driven electric motor inside a cylindrical case; and a head part which is attached to the main body so as to project from an end of the main body. The electric motor generates vibration by means of an eccentric weight attached to a rotating shaft. On a tip of the head part, there is fixed a neodymium magnet <NUM> whose external surface is coated with polyamide.

<CIT> describes a facial exercising method and apparatus. The apparatus has a generally rigid Y-shaped body with a handle portion and a pair of upwardly extending, spaced apart arm members. Each arm member has a face engaging pad. These pads can be placed against the user's face proximate to a muscle group to be exercised. An optional vibration circuit for the apparatus is also provided.

The present invention provides a handheld device for stimulating tear production in a patient as set out in claim <NUM>. Disclosed herein also is a method for stimulating tear production in a patient. The method comprises positioning a vibratory surface at a bony region on the patient's face communicating with a parasympathetic nerve which innervates the lacrimal gland. The vibratory surface is vibrated at a frequency and a displacement selected to stimulate the lacrimal nerve to produce tears. Typically, the vibratory surface will stimulate an afferent which communicates with a parasympathetic nerve which stimulates glands related to the tear film.

The vibratory surface may be vibrated at any frequency effective to stimulate the target nerves, typically being in a range from <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>. Similarly, the vibratory surface may be vibrated at any displacement effective to stimulate the target nerves, typically being in a range from <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, or <NUM> to <NUM>.

The vibratory surface typically has a skin contact area in a range from <NUM><NUM> to mm<NUM>.

The vibratory surface typically has a hardness in a range from Shore A40 to Shore A80, Shore A50 to Shore A80, Shore A60 to Shore A80, Shore A70 to Shore A80, Shore A40 to Shore A70, Shore A50 to Shore A70, Shore A60 to Shore A70, Shore A40 to Shore A60, Shore A50 to Shore A60, or Shore A40 to Shore A50.

The vibratory surface is usually formed on a polymeric interface body and may have a thickness in a range from <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, or <NUM> to <NUM>.

The polymeric interface body may have a rounded edge circumscribing at least a portion of the vibratory surface. Such a rounded edge may have a radius in a range from <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, and <NUM> to <NUM>. Alternatively, the polymeric interface body may have a square edge circumscribing at least a portion of the vibratory surface. The edge may or may not have the same properties as a central portion of the vibratory surface. For example, the polymeric interface body may have a rigid edge circumscribing at least a portion of the vibratory surface. The method of any one of claims <NUM>, wherein the vibratory surface is vibrated with a pulsed duty cycle or <NUM>%, <NUM>%, <NUM>%, <NUM>% or <NUM> %.

In some embodiments, a peak displacement of the vibratory surface may be increased when the duty cycle is less than <NUM>%.

In some embodiments, the vibratory surface may be positioned on the patient's face at a location where the patient's upper lateral nasal cartilage meets the patient's nasal bone. In such cases, the vibratory surface may be engaged against the patient's face with an upward directionality.

In some embodiments, the vibratory surface may be positioned at a location from <NUM> to <NUM> lateral to the patient's nasal midline at the region.

In some embodiments, the vibratory surface may be positioned proximate or over the parasympathetic nerve which innervates the lacrimal gland and travels through the sphenopalatine ganglia located close to the maxillary bone in the sphenopalatine fossa.

In some embodiments, the vibratory surface may be positioned by engaging the vibratory surface on a hand held device against the bony region. Usually, a patient engages the vibratory surface of the hand held device against the bony region.

In some embodiments, the vibratory surface moves in a substantially linear direction in one dimension. For example, the vibratory surface may be driven in a substantially linear direction with an excursion of <NUM> to <NUM>.

In some embodiments, the vibratory surface may be placed in a position to stimulate the external nasal nerve.

Disclosed herein is a handheld device for stimulating tear production in a patient. The device comprises a housing having a vibratory surface configured to engage a bony region on the patient's face over an afferent nerve which communicates with a parasympathetic nerve which innervates glands related to the tear film. Circuitry within the housing is configured to vibrate the vibratory surface at a frequency and a displacement selected to stimulate the afferent nerve, the lacrimal nerve to produce tears, and the Meibomian glands to produce oils to maintain the tear film.

Exemplary frequencies, displacements, skin contact areas for the vibratory surfaces, and other design features of the vibratory surfaces and devices have been set forth above with respect to the exemplary aspects of the present invention.

In other aspects of the disclosed methods and hand held device of the present claimed invention, the device circuitry may be configured to vibrate vibratory surface with a pulsed duty cycle or <NUM>%, <NUM>%, <NUM>%, <NUM>% or <NUM> %. In specific embodiments, the circuitry may be configured to increase a peak displacement of the vibratory surface when the duty cycle is less than <NUM>%.

The hand held device may be configured to be positioned by the patient so that the vibratory surface engages the vibratory surface against the bony region.

The circuitry may be configured to allow adjustment of the vibrational frequency. For example, the hand held device may include a manual frequency adjustment interface.

The hand held device may further comprise at least one non-ultrasonic vibrational transducer, typically operating at a frequency in a range from <NUM> Hzto <NUM>, 50Hzto <NUM>, <NUM> Hzto <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>, <NUM> to <NUM>.

The novel features of the invention are set forth with particularity in the appended clauses.

Sound and Ultrasound and vibration are utilized interchangeably in this description. Mechanical vibration at audible frequencies (<NUM> to <NUM>,<NUM>) may or may not actually transmit audible sound waves but may transmit force to a surface and is included in the broad definition of sound and ultrasound. Vibration, or mechanical vibration, is the broadest term and encompasses all sound or ultrasound regardless of whether pressure waves are created. Sound is simply mechanical vibration which transmits pressure waves through a medium which is then processed and "heard. " Vibration as a category encompasses ultrasound and sound as well as mechanical vibration which may not result in sound. For example, mechanical vibration may be delivered by a probe with a linear motion, a planar motion, or motion in all three axes. The important aspect of mechanical vibration is the motion and a frequency of at least a few Hertz (Hz). The underlying mechanism of purposeful vibration (as opposed to unwanted vibration created incidentally to another mechanism such as a running motor) is to and from motion intentionally created by a moving mechanism along with transduction to another medium, for example, a body tissue of a human subject. The motion of the vibration can be created by a number of different mechanisms including motors with a gear and camshaft to create an offset, an eccentric motor, a linear resonant actuator, a voice coil, and a piezoelectric mechanism. In this respect, mechanical vibration is easier to create than sound.

The frequency of the sound waves may range from the low frequency sub audible range to the higher frequency inaudible ultrasound range.

It has been determined that lower frequency (not sound) vibrations can stimulate tear production. For example, vibration at a frequency of <NUM> or <NUM> and up to <NUM> can stimulate the anterior ethmoidal nerve, the sphenopalatine ganglia, the lacrimal nerve, the facial nerves and more internal nerves and ganglia otherwise accessible only by invasive methods. For example, the lacrimal nerves or nerves proximal to the lacrimal nerve such as the sphenopalatine ganglia, the ethmoidal nerves, the vidian nerve, and the infraorbital nerves can be stimulated directly through the application of vibratory energy through the skin and bones. The energy travels through the skin and meets the bone, at which point the bone resonates to produce stimulation of the nerves. Therefore, in one embodiment, a probe <NUM> is applied to the upper eyelid and the probe delivers vibratory energy to the lacrimal gland, inducing immediate tear production.

In another embodiment, ultrasound transducers are applied to bony regions of the face and in a preferred embodiment on the orbit region to transmit ultrasound to the posterior or anterior of the eye. The ultrasound is transmitted across the bones to the retina region by conduction through the bones. Therefore, in this method, vibration is utilized to stimulate the retina via vibration of the bony structures of the orbit and resultant resonant transmission to the retina.

In another embodiment, ultrasound is applied to the skin surface of the face to facilitate exit of infection from the Eustachian tube in otitis media. In this example, the resonance of the bone agitates the infected fluid inside the Eustachian tube to assist in its expulsion. In another embodiment, the device is utilized to maintain uniform pressure in the eustachian tube, for example, during aircraft travel, during SCUBA diving, or in the case of sinusitis or a cold.

<FIG> depicts an embodiment of a device to stimulate the lacrimal gland or other nerves or ganglia transcutaneously through the skin to the nerves and ganglia. Regions <NUM>, <NUM>, and <NUM> have been shown experimentally to produce the greatest amount of nerve stimulation by way of vibration of the facial bones which in turn stimulate the nerves such as sphenopalatine ganglia, lacrimal nerve, external nasal nerve, infratrochlear nerve, supratraochlear nerve, infraorbital nerve, supraorbital nerve etc. For example, region <NUM>, when exposed to direct skin vibration at approximately <NUM> - <NUM> vibration produces copious bilateral tear formation bilaterally when just a single side is stimulated. In some embodiments, vibrations from about <NUM> to about <NUM> are utilized to stimulate the bones of the face to in turn transmit vibrations to the nerves which stimulate tear production. The treatment works best at the resonant frequency of the bone so that the vibration of the bone is maximal and affects the nerve maximally due the greatest amount of mechanical movement of the nerve and subsequent stimulation. The resonant frequency of the bone is to some extent individualized per patient. This frequency has been experimentally determined and subsequently proven to be in the range of about <NUM>-<NUM>.

Region <NUM> (<FIG>) includes the bottom eyelid (inner and outer eyelid), the medial canthus of the eye along the nasolacrimal duct. External stimulation along these regions in some embodiments stimulates the nerves through bony resonance and in some embodiments, stimulates the glands in the lower eyelid region directly.

<FIG> depicts neural pathways involved in the transduction of vibration from the skin to the lacrimal gland when vibrations are applied through the preferred external location <NUM> in <FIG>. Ganglia <NUM> projects nerves to the lacrimal nerve <NUM> which courses to the orbit to stimulate the main lacrimal gland in the superior portion of the orbit. Bone <NUM> transmits vibrations to the lacrimal nerve <NUM> and around the maxillary sinus <NUM> via the sphenopalatine ganglia. The sphenopalatine ganglia <NUM> is covered by mucosa and sits between the turbinates which are accessible transnasally through the external nasal passageways <NUM>. The external nasal nerve is a terminal branch of the ophthalmic branch of the trigeminal nerve and is directly stimulated with vibration as it is compressed against its exit from underneath the nasal bone at the junction of the nasal bone and the anterior lateral nasal cartilage. In another embodiment, an ultrasound or sound producing probe is inserted through the external nasal passageways <NUM> and applied to the mucosa in proximity to the sphenopalatine ganglia <NUM> to stimulate tear production through direct stimulation or via the nasolacrimal reflex. In another embodiment, a vibratory probe with vibration at approximately <NUM>-<NUM> is inserted into the nasal passage to directly stimulate the sphenopalatine ganglia and/or the interior anterior ethmoidal nerves on the interior of the nasal passage. In another embodiment, electrical stimulation of the external nasal nerve accomplishes tearing by activating the lacrimal nucleus in the pons and subsequently pre-gangliotic fibers within the maxillary nerve which synapse in the sphenopalatine ganglia and then stimulate the lacrimal nerve to produce tears.

In one embodiment, a method to stimulate neural pathways through the application of sound or ultrasound energy transcutaneously is described. An applicator is disposed to the face of the patient, the applicator comprising one or more vibratory elements capable of generating vibrations from about <NUM> to about <NUM>. The vibration is applied to a region close to a nerve under the skin or to a region with a bony prominence which communicates via bone structure with a nerve region located close to the skin. For example, an applicator <NUM> disposed to the region <NUM>, <NUM> (<FIG>) or <NUM> (<FIG>, <FIG>) will transmit the vibratory energy to the lacrimal glands and produce tears. The resonant frequency is different for each person as is the exact location and direction of the vibration. In one embodiment, the individual resonant frequency is determined and the device adjusted to this frequency for each person. An interface between the device and the patient's skin is similarly adjustable so that the vibrations are transmitted to the nerves in the head and neck region to be stimulated. For example, the parasympathetic nerve which innervates the lacrimal gland travels within the maxillary bone and the through the sphenopalatine ganglia is located close to the maxillary bone in the sphenopalatine fossa. At a resonant frequency of the maxillary bone, it has been discovered that the ganglia can be stimulated and tears produced. The resonant frequency is achieved through a combination of material, vibration frequency, and amplitude. For example, a material with a durometer between Shore A40 and Shore A60 vibrating over a surface area of between <NUM> mm2 and <NUM> mm2 with an amplitude of about <NUM> to <NUM> and frequency of between <NUM> and <NUM> results in copious tears. With a directionality upward and at a location approximately along the nasal bone where it meets the cartilage, tears can be produced without discomfort or sneezing or other nasal symptoms. The total force applied over the surface area in some embodiments is about 1N (Newton). In other embodiments, the total force is from about <NUM>. 5N to bout 2N. In other embodiments, the force is about <NUM>. 25N to about 4N.

<FIG> depicts the bony anatomy of the face. <FIG> depicts the nervous anatomy of the face. In <FIG>, at the point where the upper lateral cartilage meets the nasal bone, the external branch of the anterior ethmoidal nerve penetrates the nasal bone is depicted. This location is where the lateral process of the septal nasal cartilage meets the nasal bone (<FIG>) and <NUM> in <FIG>. This is the location, located on the skin, which has been discovered through experimentation to produce tears when mechanical vibration is applied at a frequency of <NUM>-<NUM> with a vibration amplitude of approximately <NUM> to <NUM> and/or force of about <NUM> to <NUM>.

Furthermore, it has been discovered that direct stimulation of the infratrochlear and infraorbital nerves with mechanical vibration also induces lacrimation.

Mechanical vibration can also stimulate lacrimation by direct contact with the mucosal surfaces inside the nose.

<FIG> depicts the neural anatomy of this region underneath the skin. The anterior ethmoidal nerve, a direct continuation of the nasociliary nerve, splits into two branches to supply the nasal mucosa, medial and lateral, as it enters the nasal cavity where is supplies the nasal mucosa. The nasociliary nerve continues to the caudal region of the nasal bone and appears <NUM> to <NUM> from the midline as the external nasal nerve (Prendergast in Shaiiman, MA and Giuseppe AD Advanced Aesthetic Rhinoplasty. Springer-Verlag <NUM>). The infraorbital nerve <NUM> exits the bone and travels into the skin approximately <NUM>-<NUM> below the lower eyelid. It is the external nasal nerve which has been determined to induce tearing when vibrations at <NUM>-<NUM> are applied. Electrical stimulation (bipolar or monopolar) of the external nasal nerve in this region also can be utilized to induce lacrimation.

A well described pathway for lacrimation is called the nasolacrimal reflex in which stimulation of afferent fibers of the anterior ethmoidal nerve (accessible inside the nose) travel through the ophthalmic nerve to the salivary nucleus in the brain stem (<NPL>), then parasympathetic nerve signals travel via the maxillary branch of the trigeminal synapse in the sphenopalatine ganglia to innervate the lacrimal nerve and stimulate the lacrimal glands. Parasympathetic fibers generally stimulate the lacrimal glands and also partially innervate the Meibomian glands.

In addition to the specific descriptions set forth herein, it has been discovered through extensive experimentation that stimulation of the external nasal nerve achieves lacrimation. As described above, the external nasal nerve <NUM> exits deep to the layers of the skin through an orifice <NUM> at the junction of the nasal cartilage <NUM> and nasal bone <NUM>. It is not accessible by electrical stimulation. As described herein, certain vibrational parameters result in stimulation of lacrimation similar to the nasolacrimal reflex.

<NPL>) characterized the anatomy of the external nasal nerve in cadaver specimens. The external nasal nerve is a continuation of the nasociliary nerve which originates from the ophthalmic branch of the trigeminal nerve. Prior to its exit from the inner portion of the nose to the external portion of the nose, it gives off two branches to the inner portion of the nose. The external nasal branch is the terminal nerve of the nasociliary nerve. After exiting the inner portion of the nose between the nasal bone and the upper lateral cartilage (through a notch in the nasal bone), the external nasal nerve dips into the fibrofatty tissue to ultimately branch and supply the skin and fatty tissues of the distal nose. The exit was consistently <NUM> - <NUM> lateral to the nasal midline independent of the width of nose. There were there branching patterns identified. The first was a single nerve exiting the nasal bone. The second pattern was splitting of the nerve upon exit from the nasal bone and the third pattern was splitting of the nerve distal to the exit from the nasal bone close to the cartilage of the distal region of the nose. The nerve size in this study was consistently <NUM> to <NUM> diameter.

Therefore, in one embodiment, a device is placed approximately <NUM> to <NUM> lateral to the nasal midline at the region where the upper lateral cartilage meets the nasal bone. The device is placed unilaterally or bilaterally or unilaterally and then sequentially on the contralateral side for bilateral treatment. The device applies a force over an are of <NUM>-<NUM><NUM> on the nose at frequency of <NUM>-<NUM>. In some embodiments, approximately <NUM> to about <NUM> Newtons (N) of force is applied to the external nasasl nerve as it leaves the nasal bone. In other embodiments, a force of approximately <NUM> to about <NUM> N is applied to the nose to activate the external nasal nerve.

In another embodiment in <FIG>, the nasolacrimal duct is the target. It has been found in clinical work that stimulation of this duct internally along its length leads to stimulation of tear production. The mechanism is thought to be direct stimulation of the nasolacrimal reflex. It has been further discovered that vibration at <NUM>-<NUM> externally through the skin in the region of the bone through which the duct travels (e.g. nasal bone) also stimulates this reflex. Similar to the external nasal nerve, electrical stimulation has been found to be ineffective in the stimulation of the reflex through this anatomy.

The effector interface with the face of the patient is a very important component of the energy transmission to promote safety and tolerability of the procedure. Through experimentation, the optimal durometer is somewhere between Shore 40A (pencil eraser) and Shore 80A (leather). Shore 60A is about a car tire tread and Shore 70A is a running shoe sole. With an interface which is too hard, the skin is abraded and with an interface which is too soft, the nerve is not effectively stimulated.

It has been determined that unfocused vibration at <NUM> to about <NUM> leads to general activation of the sphenopalatine ganglion, lacrimal nerve, external nasal nerve, infratrochlear nerve, infraorbital nerve, supraorbital nerve, or internal nasal nerve leading to inhibition of rhinitis like symptoms by overstimulation and/or relief from nasal congestion, migraines, narcolepsy, dry mouth, dry eye, and elevated intra-ocular pressure via neuromodulation. Focused, or directed vibration, be it sound in which the vibrating waves are directed toward the skin and bone by way of positioning the probe toward the nasopalatine ganglia, external nasal nerves, or eyelids, or lacrimal nerves have been determined to be more effective in eliciting specific pathways such as lacrimation.

<FIG> depicts a device usable to activate the lacrimation pathway by applying vibration to the side of the nose and/or lacrimal pathway to activate the external nasal nerve as it exits the nasal bone onto the skin of the nose. Vibratory energy at <NUM>-<NUM> with <NUM> excursion and <NUM>-4N of force stimulates the external nasal nerve when then energy is applied to the region with a sufficiently rigid biocompatible material.

<FIG> depicts the structural details of the ultrasound transmission from the skin through the bone and to the nerves which lie beneath the bones of the face. The end effector <NUM> of the device <NUM> communicates with the skin <NUM> and from there, the vibrations travel through the skin <NUM> to the bone <NUM> and to the mucous layer <NUM> underneath. From the bone, the vibration can be transmitted to the nerves in other regions of the face such as the sphenopalatine ganglia, the infraorbital nerve, the orbital nerve, the facial nerve, the trigeminal nerve, the ethmoidal nerve, and ultimately, the lacrimal nerve.

Direct stimulation of the mucous layer through bone also will accomplish direct treatment of sinus disease in addition to its effect on the nerves. Vibration and/or ultrasound stimulation of the mucosal layers will affect congestion directly by unplugging the outflow pathways and equalizing pressure.

<FIG> depicts several of the bony pathways which can communicate with nerve pathways via neuroacoustic conduction present inside the cranium <NUM> and facial bones. The maxillary sinus and bone <NUM> are the predominant pathway for transmission of vibratory energy to the sphenopalatine ganglia and ultimately the lacrimal nerve and gland. The conchae <NUM> are folds of the maxillary bone which protrude partially into the nasal cavity. The conchae protect the olfactory bulb as well as the sphenopalatine ganglia but also play a role in transmission of sounds. The maxillary bone and its conchae communicate with the zygomatic bone <NUM>. The mandible <NUM> represents an additional, albeit less direct pathway, for stimulation of the nerves of the facial region. In a preferred embodiment, a resonant frequency for these bones is utilized in order to transmit vibrational energy to the nerves within or below the bone to achieve a clinical end such as generating tears in the eye, stopping cluster headaches, migraines, seizures, rhinitis, and nasal congestion.

<FIG> depict various end effectors <NUM> (<FIG>) of the device <NUM> through which the vibratory energy is delivered transcutaneously to stimulate nerves of the facial regions, specifically the external nasal nerve.

<FIG> depicts an effector which is approximately <NUM> in diameter and longer than <NUM>. The tip is relatively flat and soft so that it can be depressed against the skin along the side of the nose to couple energy to the bone and the nerves beneath. The tip <NUM> is rounded at its end and may be produced from a hydrophilic substance or a hydrogel or a more firm, harder material to facilitate coupling with the skin. A portion of the tip is more firm and rigid than another portion so that vibrational energy has a preferential direction as it is transmitted to and through the skin.

<FIG> depicts optional rings <NUM> or constraining structures which circumscribe the tissue-engaging end of the tip to further enhance the ability of the tip to transfer vibrational energy into the skin.

<FIG> depicts another embodiment of an end effector to transmit energy through the skin to the bones and to the nerves underneath. In this example, the end effector is in the form of a small paddle <NUM> with a thin flexible neck <NUM> which can be applied to the skin regions which transmit vibratory energy to nerves. This embodiment allows the user to apply a variable pressure to the skin to modulate the vibration through the skin and bone to the nerve.

<FIG> is another embodiment of an end effector. In this example, the end effector <NUM> is soft and compliant with an outer layer <NUM> made from a hydrogel or other slippery material. A backing layer is disposed outside the slippery material so that the end effector can be depressed against the skin. The end effector may have an edge between <NUM> and <NUM> thick, the end (edge radius) being rigid so it may be depressed in the ridge on the side of the nose where the nasal cartilage meets the bone. The end can be rounded in some embodiments with a radius of curvature of <NUM> to <NUM>. The lateral curvature of the edge determines the sharpness of the tip, a key factor in the stimulation of the external nasal nerve. The smaller the radius and more severe the drop off along the radius to the outermost edge of the tip, the sharper the tip becomes.

<FIG> depicts the expanded components of one embodiment of a device to stimulate tears <NUM>. <NUM> is the housing with an advanced user interface to allow for gripping the device and then applying to the external nasal nerve of a patient. Grip <NUM> is a user interface for the device which contacts the palm of the user to allow for manipulation of the device while the biocompatible tip <NUM> is manipulated and applied to the skin of the patient. The material is biocompatible and firm. Speaker or voice coil <NUM> is the heart of the system, allowing for a continuous spectrum of frequencies, from <NUM> all the way to kHz frequency as well as modulation of driving amplitude. Skin interface <NUM> is stabilized by frame <NUM>. Frame <NUM> also enables finger grips for further manipulation of the device. The skin interface <NUM> is a biocompatible skin interface which allows for the application of cyclic force to the external nasal nerve, compressing the nerve against the nasal bone at a frequency of approximately <NUM> to stimulate the nerve to generate tears. Shaft <NUM> underneath the end effector is driven by the speaker to then drive the end effector element <NUM>. Interface <NUM> provides the transduction interface between the speaker <NUM> and the end effector <NUM>.

<FIG> depicts nasal anatomy. The frontal bone <NUM> forms the upper boundary of the orbit and maxillary bone <NUM> forms the medial boundary of the orbit. The frontal bone forms the roof of the frontal sinus. Maxillary bone forms the roof of the maxillary sinus <NUM>. The nares <NUM> is the communication between the outside and the internal mucosa of the nose. The external nasal nerve <NUM> leaves the nasal cavity through an orifice <NUM> between the nasal bone <NUM> and the lateral processes of the septal nasal cartilage <NUM>. It has been discovered that stimulation of the external nasal nerve in this region <NUM> with force between <NUM>-<NUM> N using vibration at <NUM>-<NUM> results in several clinical effects including creation of tears, abrogation of allergic and vasomotor rhinitis, relief from sinusitis, stimulation of Meibomian glands, treatment of headaches, and narcolepsy.

<FIG> depicts the cutaneous nervous anatomy <NUM> in and around the nasal cavity. Cutaneous, or subcutaneous, generally refers to nerves covered by skin, dead stratified squamous, keratinized epithelial cells. In contrast, mucosa or sub-mucosal, nerves are covered by non-keratinized mucosal epithelial cells which are generally ciliated and columnar. Cutaneous nerves are more difficult to reach with certain energy forms (e.g. electrical stimulation) because the dead stratified layers broadly diffuse the current. However, vibratory stimulation can be directed to the nerves underlying the skin by transmission of pressure waves. The external branch of the anterior ethmoidal nerve <NUM>, also referred to as the external nasal nerve, exits at the caudal portion of the nasal bone and supplies the ipsilateral side of the nose with cutaneous nerve fibers. Infraorbital nerve <NUM> supplies cutaneous fibers to the lower eyelid, upper lip, and a portion of the nasal vestibule; the vestibule is the most anterior part of the nose, lined by the same epithelium as the skin. Its epithelium transitions to the respiratory epithelium of the nasal cavity proper. The infratrochlear nerve <NUM> supplies the skin of the upper eyelids, bridge of the nose, the conjunctiva, lacrimal sac, and the caruncle (small, pink, globular nodule at the inner corner of the eye made of skin covering the sebaceous and sweat glands). The supratrochlear nerve <NUM> supplies the skin of the lower forehead, the conjunctiva and the skin of the upper eyelid. It has been discovered through experimentation described herein that vibratory stimuli (e.g. <NUM> to approximately <NUM>) of these nerves and nerve endings stimulate the lacrimal nerve to secrete tears. In these embodiments, the vibratory stimuli contact the stratified epithelium of the skin not the mucosa and energy is transferred by mechanical waves.

<FIG> depicts a handheld embodiment of a device <NUM> to apply vibrational energy to the facial region in which there is an underlying parasympathetic nerve or a circuit which ultimately results in stimulation of a parasympathetic nerve. Interface <NUM> moves with linear excursion substantially perpendicular to the housing <NUM>. Housing <NUM> is configured to be handheld and self-contained, produced from a comfortable, biocompatible plastic or aluminum material. Interface <NUM> is fairly rigid with a rounded yet firm tip. The radius of curvature of the tip is such that it can firmly push into the junction of the nasal cartilage and nasal bone, vibrate a <NUM>-<NUM>, preferably between <NUM> and <NUM> or at least between <NUM> and <NUM> with maintenance of a constant speed despite the force being applied by the user to the nerve.

<FIG> depicts a detailed view of the handheld device in <FIG>. The basic mechanism of this device is a voice coil <NUM> which provides for a linear driving motion of the tip <NUM>. Plastic body <NUM>, <NUM> surrounds the device. An optical distance sensor <NUM> is calibrated to detect movement of the linear vibrating component <NUM>. Printed circuit board assembly <NUM> comprises an amplifier and battery charging circuitry as well as an optional control system so that the tip <NUM> vibrates at a near constant frequency. Power button <NUM> and cover <NUM> as well as lithium ion batteries <NUM> and <NUM> complete the unit. This unit is self-contained and the lithium ion batteries are rechargeable.

<FIG> depicts the components of a vibratory device <NUM> which is configured to be held in the palm of the hand of the user with an interface with the tip of a finger of a user. Body surface interface <NUM> is configured to be handheld and comfort grip <NUM> is configured from a biocompatible material. Lithium ion <NUM> battery is inserted into the main body housing <NUM>. Linear vibration motor <NUM> travels with linear motion and is connected to the body surface interface to create linear motion as well. The surface interface is applied to the skin with perpendicular application to the skin to stimulate the external nasal nerve and the parasympathetic nervous system to open Meibomian glands, create secretions of oils, and produce tears from the lacrimal glands, treat migraines, epilepsy, narcolepsy, headaches, open blood brain barrier, equalize pressure, treat rhinitis and sinusitis, and nasal polyps. Tactile switches <NUM> enable user guided feedback to increase or decrease stimulation level, either by signaling adjustment of the vibration amplitude and/or frequency.

<FIG> depicts another embodiment of a device <NUM> configured to apply vibrational energy to a nerve overlying a parasympathetic nerve of the face. Interface <NUM> is a biocompatible skin interface designed to transfer force from the vibratory element to the skin overlying the bone of the patient and to the nerve underlying the bone. A snap element <NUM> allows for quick placement and removal of the skin interface <NUM>. The vibration is generated by eccentric motor <NUM> which vibrates the biocompatible interface with an approximately planar and perpendicular vibratory direction to the long axis of the device <NUM>. Switch <NUM> powers the device on and off. Rechargeable battery <NUM> and electrical access port <NUM> enable power delivery to the device <NUM>. Additional electronics <NUM> may include a lockout timer so that a user does not over use the device. A control system to maintain a pre-specified motor and vibration speed is also an optional feature of the circuitry. The electronics are housed in shell <NUM>.

<FIG> depicts an embodiment of a vibratory device <NUM> in which vibratory energy is applied to the mucocutaneous junction where the skin of the eyelid meets the conjunctiva. The nerve endings of the eyelid are stimulated in this embodiment and energy is applied to the mucocutaneous junction to create tears and unblock and stimulate Meibomian glands. Device <NUM> comprises a vibratory, sound, or ultrasound generating component which can be coupled to the eyelid. In one embodiment, the device further incorporates suction to grab on to the eyelid during the treatment. In another embodiment, the device incorporates a grip like a pair of tweezers or forceps to hold the eyelid while the energy is applied.

<FIG> depicts the inner workings <NUM> of the device in <FIG> which applies vibrational energy to the mucocutaneous junction of the eyelid. Pressure sensitive switch <NUM> controls the vibrational energy with pressure. Importantly, eyelid interface <NUM> in configured to interface with the eyelid. It is comprised of a biocompatible material and comprises a mechanism to pull away the eyelid while applying vibration or ultrasound so as to protect the sclera and cornea. A standard motor <NUM> drives the device <NUM>. Optionally, the motor <NUM> is connected to a weight <NUM> to create eccentricity and vibration. Elastomer pad <NUM> is a biocompatible interface with the skin of the patient or device user. The pad is characterized by a shore durometer of between 20A and 50A. In another embodiment, a linear resonant actuator is utilized to couple vibration to the mucocutaneous junction of the eyelid. In this embodiment, vibrations of about <NUM> to <NUM> have been found to be optimal to stimulate the nerve endings in the conjunctiva present on the eyelid. The pathway in this embodiment is presumed to be both a neural reflex pathway and mechanical pathway in which the glands are stimulated.

<FIG> depicts a component break out of the device in <FIG> and <FIG>. <NUM> is a pressure sensitive switch which when depressed creates a larger vibration excursion or less excursion depending on what the user prefers. <NUM> is a top cover for the device and <NUM> is an eccentrically weighted motor. The motor is connected to the drive shaft <NUM> to move the biocompatible patient interface <NUM>. The device is housed with aluminum <NUM> or plastic with smooth edges. Rechargeable battery <NUM> is regulated by voltage regulator <NUM> to supply DC motor <NUM>. DC motor <NUM> almost might be linked to a rotating cam to move a piston in a direction perpendicular to the motor to then be applied to the skin of a patient to activate a nerve through the skin.

<FIG> depict an embodiment wherein the vibrating elements are attached to the fingertips of the patient. Linear resonant actuators or eccentric motors are utilized in the fingertip devices. Fingerband <NUM> allows the user's finger to be attached to the device. Biocompatible coupling <NUM>, <NUM> facilitates the user application of the device to the skin of the user. Pressure sensor <NUM> allows pressure controlled modulation of the frequency or amplitude of the end effectors which provide the energy to the skin of the user.

<FIG> depicts a device <NUM> which can be applied bilaterally to the nose of a patient to stimulate the external nasal nerve simultaneously or individually depending on patient preference. A feature of this device is that it has haptic feedback such that as the patient presses down on the device and on the nose, the device responds by applying a greater force or displacement to ensure nerve stimulation.

<FIG> depicts the underside of the device shown in <FIG>. Pressure sensors <NUM> sense the force being applied by the user. Material <NUM> is preferably flexible so that the user can squeeze the device and compress the external nasal nerve and apply increasing vibrational force, the degree of which is dictated by the force the pressure sensor senses on the skin. The device Is rechargeable via port <NUM> which can also potentially serve as a data port.

<FIG> depicts a schematic of a portion of the device shown in <FIG>. The drive electronics and programming are contained in this component of the device from <FIG> and is designed to fit in the palm of the hand of the user. Cables <NUM> extend to the finger effectors and finger straps shown in <FIG>. Lithium ion battery allows for recharging of the unit. Switch <NUM> is a voice activated switch or simple toggle on-off which is activated by the user. Plastic body <NUM> houses the circuitry and battery and is comprised of aluminum of plastic. Circuit board assembly <NUM> contains control circuitry including voltage regulator and optionally feedback so that the motors can operate continuously.

<FIG> depicts a schematic of the individual components of the device shown in <FIG>. Pressure sensors <NUM> enable coupling between the force applied by the user and the speed, torque, and force of the eccentric motors <NUM> which create the vibratory effect to stimulate the external nasal nerve and parasympathetic pathway. Element <NUM> is a housing for electronics and for the patient to grip while applying the vibration to the external nasal nerve and parasympathetic pathway. Battery <NUM> is preferably rechargeable but also may be a replaceable battery. Cover <NUM> seals the electronic circuit board <NUM> and charge port <NUM>.

<FIG> depicts a preferred embodiment <NUM> in which the end effector interface <NUM> moves in a linear direction, actuated by a cam <NUM> mechanically connected <NUM> to an electric motor <NUM>. Rotation of the motor linked to the cam <NUM> drives a piston <NUM> with an end <NUM> which also serves as the biocompatible interface with an edge adapted to activate a nerve such as the external nasal nerve. The piston <NUM> and biocompatible interface <NUM> move at an optimal frequency between <NUM> and <NUM> or between <NUM> and <NUM>. The cam <NUM> can be offset from the central axis <NUM> to determine the excursion of the piston (e.g. <NUM>) and interface which then applies force to the skin of the patient and then to the nerve to be stimulated. In some embodiments, a governor is included to ensure that the frequency that is set by the user or pre-determined before delivery to the user is the actual frequency of the piston excursion. For example, in one embodiment, a photodiode or other detector is utilized to detect motion of the electric motor, linkages, or the piston; if the revolutions per minute (RPM) are not as pre-specified, additional current is added or subtracted from the motor. Electronic circuitry is also included which enables the device to record the time of treatment, time between treatments as well as a lock out time in between treatments (e.g. to ensure that the device is not overused or underused). Such data is stored in memory and is downloadable offline to a PC as a record of usage and compliance with the device in real world practice or in a clinical trial setting. The circuit further controls the voltage to ensure a constant power to the motor and constant rotation which can be pre-set or varied by the user.

Claim 1:
A handheld device for stimulating tear production in a patient, said device comprising:
a hand-holdable housing (<NUM>) having a vibratory surface for engaging a bony region on the patient's face over an afferent nerve which communicates with a parasympathetic nerve which innervates glands related to the tear film,
wherein the vibratory surface is provided by an interface (<NUM>) configured to move with linear excursion substantially perpendicular to the hand-holdable housing, wherein the interface has a rounded yet firm tip with a radius of curvature such that the tip may firmly push into the junction of the nasal cartilage and nasal bone; and
circuitry within the hand-holdable housing configured to vibrate the rounded tip at a frequency in a range from <NUM> to <NUM>, with a force in the range of <NUM> N to <NUM> N and a displacement in a range from <NUM> to <NUM> and wherein the vibratory surface has a skin contact area in a range from <NUM><NUM> to <NUM><NUM>.