XPRESS MULTI-SINUS DILATION TOOL

K121174 · Entellus Medical, Inc. · LRC · May 17, 2012 · Ear, Nose, Throat

Device Facts

• Record ID: K121174
• Device Name: XPRESS MULTI-SINUS DILATION TOOL
• Applicant: Entellus Medical, Inc.
• Product Code: LRC · Ear, Nose, Throat
• Decision Date: May 17, 2012
• Decision: SESE
• Submission Type: Special
• Regulation: 21 CFR 874.4420
• Device Class: Class 1
• Attributes: Therapeutic

Intended Use

To access and treat the frontal recesses, sphenoid sinus ostia and maxillary ostia/ethmoid infundibula in adults using a trans-nasal approach. The bony sinus outflow tracts are remodeled by balloon displacement of adjacent bone and paranasal sinus structures.

Device Story

XprESS Multi-Sinus Dilation Tool is a manual surgical instrument for sinus balloon dilation. Device features a re-shapeable distal end, curved suction tip, and balloon inflation port. Physician tracks device to sinus ostium using endoscopic visualization; performs balloon dilation to remodel bony sinus outflow tracts. Suction/irrigation capabilities provided via proximal barbed fitting. Used in clinical settings by physicians. Benefits include minimally invasive remodeling of sinus structures. Single-use, sterile device.

Clinical Evidence

No clinical data submitted. Performance supported by design verification testing and simulated use in a cadaver model to confirm device integrity across multiple inflations and tip manipulations.

Technological Characteristics

Manual ENT surgical instrument. Features re-shapeable distal end, 2mm atraumatic ball tip, and balloon inflation mechanism. Materials and biocompatibility identical to predicate. Sterile, single-use. No electronic components or software.

Indications for Use

Indicated for adults requiring treatment of frontal recesses, sphenoid sinus ostia, and maxillary ostia/ethmoid infundibula via trans-nasal approach. Contraindicated in patients with nickel or barium sulfate allergies; do not attach to CT Image Guidance systems.

Regulatory Classification

Identification

An ear, nose, and throat manual surgical instrument is one of a variety of devices intended for use in surgical procedures to examine or treat the bronchus, esophagus, trachea, larynx, pharynx, nasal and paranasal sinus, or ear. This generic type of device includes the esophageal dilator; tracheal bistour (a long, narrow surgical knife); tracheal dilator; tracheal hook; laryngeal injection set; laryngeal knife; laryngeal saw; laryngeal trocar; laryngectomy tube; adenoid curette; adenotome; metal tongue depressor; mouth gag; oral screw; salpingeal curette; tonsillectome; tonsil guillotine; tonsil screw; tonsil snare; tonsil suction tube; tonsil suturing hook; antom reforator; ethmoid curette; frontal sinus-rasp; nasal curette; nasal rasp; nasal rongeur; nasal saw; nasal scissors; nasal snare; sinus irrigator; sinus trephine; ear curette; ear excavator; ear rasp; ear scissor, ear snare; ear spoon; ear suction tube; malleous ripper; mastoid gauge; microsurgical ear chisel; myringotomy tube inserter; ossici holding clamp; sacculotomy tack inserter; vein press; wire ear loop; microrule; mirror; mobilizer; ear, nose, and throat punch; ear, nose and throat knife; and ear, nose, and throat trocar.

Predicate Devices

• XprESS Multi-Sinus Dilation Tool (K112506)

Submission Summary (Full Text)

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12 1174

MAY 1 7 2012

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### 510(k) Summary

Date Prepared: Submitter Information: April 16, 2012 Entellus Medical, Inc. 6705 Wedgwood Court, North Maple Grove, MN 55311

Establishment Registration:

Contact Information:

3006345872

Karen E. Peterson Vice President Clinical, Regulatory and Quality [phone] [e-mail]

Device Information: Trade Name: Common Name: Classification Name: Product Code: Regulation Number:

XprESS Multi-Sinus Dilation Tool Sinus Balloon Dilation System ENT Manual Surgical Instrument LRC Class I, 21 CFR 874.4420

XprESS Multi-Sinus Dilation Tool [K112506]

# Predicate Device: Device Description:

The XprESS Multi-Sinus Dilation Tool is intended to remodel or recreate the sinus outflow tract via trans-nasal balloon dilation. The XprESS device combines features of a curved suction tip and a frontal ostium seeker with the tissue expansion effect of balloon dilation. The familiar features of this device enable a physician to track the device to the sinus ostium using endoscopic visualization. Since the distal end of the device is re-shapeable, one balloon can be modified to work on multiple sinuses within the same patient.

Image /page/0/Figure/15 description: The image shows a medical tool called the XprESS Multi-Sinus Dilation Tool. The tool has a curved suction tip on one end and a balloon inflation port on the other. There is also a release knob mechanism in the middle of the tool and a threaded fitting on the end.

The XprESS device curved suction tip has a 2 mm atraumatic ball tip with a 1 mm inside diameter. A suction tube may be connected to the proximal barbed fitting to provide active suction by covering the suction vent. An Infusion Line connected to a syringe may be connected to the proximal barbed fitting to provide irrigation. The device was designed to prevent fluid from exiting the suction vent during irrigation.

The XprESS Multi-Sinus Dilation Tool is provided sterile and for single use only.

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The items packaged with the XprESS Multi-Sinus Dilation Tool include the Inflation Device, Bending Tool and two Infusion Lines.

XprESS is available in the following balloon sizes. Both balloon lengths are appropriate for treating all sinuses; selection is based on physician preference.

| Balloon Diameter (mm) | Balloon Length (mm) |
|-----------------------|---------------------|
| 5 | 18 |
| 6 | 8 |
| 6 | 18 |
| 7 | 18 |

The XprESS Multi-Sinus Dilation Tool has been tested to withstand multiple inflations and device tip manipulations in a surgical case wherein all 6 sinus ostia are being dilated.

#### Indication for Use:

To access and treat the frontal recesses, sphenoid sinus ostia and maxillary ostia/ethmoid infundibula in adults using a trans-nasal approach. The bony sinus outflow tracts are remodeled by balloon displacement of adjacent bone and paranasal sinus structures.

### Contraindications:

- Do not use this XprESS device in patients who are allergic to nickel or barium sulfate. .
- Do not attach the XprESS device directly to the CT Image Guidance systems. This may . result in inaccurate device positioning.

#### Technological Characteristics:

The XprESS device has the same indications for use and fundamental scientific technology as the predicate device [K112506]. The subject device has the same technological characteristics (i.e., principle of operation, basic design, function, materials, biocompatibility, packaging, shelf life and sterilization) as the predicate device.

#### Substantial Equivalence:

The XprESS device has the same indications for use and fundamental scientific technology as the predicate device. The XprESS device is substantially equivalent to the predicate device.

#### Performance Data:

Performance testing of the XprESS device consisted of design verification testing and simulated use in a cadaver model to support.the additional balloon size. Sterilization, packaging testing, biocompatibility, animal and clinical data was not submitted. Performance testing showed that the device meets design specifications and performed as intended.

#### Conclusion:

Conclusion, the indications for use and technological characteristics are the same as or equivalent to the predicate device. Performance testing has demonstrated that the device is safe and effective and that its performance is substantially equivalent to the predicate device.

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### DEPARTMENT OF HEALTH & HUMAN SERVICES

Image /page/2/Picture/1 description: The image shows the logo for the U.S. Department of Health & Human Services. The logo features a stylized depiction of an eagle or bird-like figure with three curved lines representing its body and wings. The logo is surrounded by text that reads "DEPARTMENT OF HEALTH & HUMAN SERVICES - USA" in a circular arrangement.

#### Public Health Service

Food and Drug Administration 10903 New Hampshire Avenue Document Control Room -WO66-G609 Silver Spring, MD 20993-0002

Entellus Medical, Inc. . c/o Ms. Karen E. Peterson Vice President Clinical, Regulatory and Quality 6705 Wedgwood Court North Maple Grove, MN 55311

Re: K121174

Trade/Device Name: XprESS Multi-Sinus Dilation Tool Regulation Number: 21 CFR 874.4420 Regulation Name: Ear, Nose, and Throat Manual Surgical Instrument Regulatory Class: Class I Product Code: LRC Dated: April 16, 2012 Received: April 17, 2012

Dear Ms. Peterson:

We have reviewed your Section 510(k) premarket notification of intent to market the device referenced above and have determined the device is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate for associated in the May 28, 1976, the enactment date of the Medical Device Amendments, or to devices that have been reclassified in accordance with the provisions of the Federal Food, Drug, and Cosmetic Act (Act) that do not require approval of a premarket approval application (PMA). and Cosmetic (110.) that be nevice, subject to the general controls provisions of the Act. The r ou may, atere, mans of the Act include requirements for annual registration, listing of general controls provisions of vactice, labeling, and prohibitions against misbranding and adulteration. Please note: CDRH does not evaluate information related to contract liability addition. Trease now

If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to additional controls. Existing major regulations affecting your device can be may be subject to additions, Title 21, Parts 800 to 898. In addition, FDA may publish further announcements concerning your device in the Federal Register.

MAY 1 7 2012

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## Page 2 - Ms. Karen E. Peterson

Please be advised that FDA's issuance of a substantial equivalence determination does not mean that FDA has made a determination that your device complies with other requirements of the Act or any Federal statutes and regulations administered by other Federal agencies. You must comply with all the Act's requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part 801); medical device reporting (reporting of medical device-related adverse events) (21 CFR 803); good manufacturing practice requirements as set forth in the quality systems (QS) regulation (21 CFR Part 820); and if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050.

If you desire specific advice for your device on our labeling regulation (21 CFR Part 801), please go to http://www.fda.gov/AboutFDA/CentersOffices/CDRH0ffices/ucm115809.htm for the Center for Devices and Radiological Health's (CDRH's) Office of Compliance. Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21CFR Part 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to

http://www.fda.gov/MedicalDevices/Safety/ReportaProblem/default.htm for the CDRH's Office of Surveillance and Biometrics/Division of Postmarket Surveillance.

You may obtain other general information on your responsibilities under the Act from the Division of Small Manufacturers, International and Consumer Assistance at its toll-free number [phone] or [phone] or at its Internet address

http://www.fda.gov/MedicalDevices/Resourcesfor You/Industry/default.htm.

Sincerely yours,

Evelin Kuan, MD

Malvina B. Eydelman, M4 Director Division of Ophthalmic, Neurological, and Ear, Nose and Throat Devices Office of Device Evaluation Center for Devices and Radiological Health

Enclosure

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#### Indications for Use Statement 6. .

510(k) Number (if known):

KI21174

Device Name:

XprESS Multi-Sinus Dilation Tool

Indications for Use

To access and treat the frontal recesses, sphenoid sinus ostia and maxillary ostia/ethmoid infundibula in adults using a trans-nasal approach. The bony sinus outflow tracts are remodeled by balloon displacement of adjacent bone and paranasal sinus structures.

(PLEASE DO NOT WRITE BELOW THIS LINE-CONTINUE ON ANOTHER PAGE IF NEEDED)

Concurrence of CDRH Office of Device Evaluation (ODE)

OR/AND X Prescription Use

Over-the-Counter Use

Daniel C. Ceppar

(Division Sign-Off) Division of Ophthalmic, Neurological and Ear, Nose and Throat Devices

510(k) Number K121174