Citation Nr: 0307267 Decision Date: 04/15/03 Archive Date: 04/24/03 DOCKET NO. 97-28 856A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for hiatal hernia and esophagitis. 2. Entitlement to service connection for sinusitis. 3. Entitlement to service connection for hypertension. 4. Entitlement to service connection for a left shoulder disability. 5. Entitlement to service connection for tinnitus. 6. Entitlement to service connection for labyrinthitis. (The issue of entitlement to a rating greater than 20 percent for a cervical spine disability will be the subject of a later decision.) REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Panayotis Lambrakopoulos, Counsel INTRODUCTION The veteran served on active duty from February 1967 to October 1968, from May 1973 to November 1975, and from January 1976 to August 1996. This matter comes before the Board of Veterans' Appeals (Board) in part from January 1997 and later RO decisions which collectively denied service connection for hiatal hernia and esophagitis, sinusitis, hypertension, a left shoulder disability, tinnitus, and labyrinthitis. Those issues are addressed in the present Board decision. The veteran also appeals for a rating higher than 20 percent for a cervical spine disorder. The Board is undertaking additional development, pursuant to 38 C.F.R. § 19.9, on that issue. After that development is completed, the Board will prepare a separate decision addressing this issue. In August 2000, the veteran withdrew his appeal of multiple other issues, including service connection for a right inguinal hernia and for a right ankle disorder, and entitlement to a higher rating for a lumbar spine disorder. Thus such issues are not before the Board at this time. 38 C.F.R. § 20.204. FINDINGS OF FACT 1. The veteran's current hiatal hernia and esophagitis began in service. 2. The veteran's current sinusitis began in service. 3. The veteran's has a history of labile hypertension; he does not currently have the disability of persistent essential hypertension. 4. The veteran's current left shoulder disorder began in service. 5. The veteran's current tinnitus began in service. 6. The veteran's current benign paroxysmal positional vertigo, diagnosed as labyrinthitis in service, began in service. CONCLUSIONS OF LAW 1. Hiatal hernia and esophagitis were incurred in by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2002). 2. Sinusitis was incurred in active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2002). 3. Claimed hypertension was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2002). 4. A left shoulder disability was incurred in active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2002). 5. Tinnitus was incurred in active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2002). 6. Benign paroxysmal positional vertigo, claimed as labyrinthitis, was incurred in active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2002). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual background The veteran served on active duty in the Navy from February 1967 to October 1968, from May 1973 to November 1975, and from January 1976 through August 1996, at which point he retired based on length of service. Service medical records show that when the veteran had complaints of earaches in March 1968, his canals were found impacted with wax. External otitis was diagnosed in June 1968. On examination in September 1977, a scarred right eardrum was noted. In January 1978, he was seen for viral syndrome and questionable hypertension with dizziness and nausea; several blood pressure readings were elevated (138/92, 158/102, 144/98, 138/104, 138/102, 142/118, 144/108, 138/108, 142/92, 148/104). By February 1978, blood pressure was 132/78 and the results were "OK." In January 1984, he reported positional vertigo for the past 3 days, with blurring of vision and lightheadedness; the assessment was serous otitis media. The impression in March 1984 was benign labyrinthitis. On annual examination in February 1985, his blood pressure was 140/90 and 130/85; he also reported indigestion and dizziness. Rhinorrhea was noted in July 1985 and ethmoidal sinus problems in August 1986. On annual examination in July 1987, he reported swollen or painful joints, broken bones, and rupture/hernia. On annual physical examination in June 1988, he referred to dizziness or fainting spells, sinusitis, rupture/hernia, broken bones, and swollen or painful joints. Blood pressure in July 1988 was 114/72. In October 1988, he complained of recurrent episodes of paranasal congestion, postnasal drip, and sinus pain in the maxillary area; based on sinus X-rays, the diagnosis was chronic sinusitis with superimposed infection at that time. In February 1993, notes indicate sinusitis; also blood pressure at that time was 131/75. In April 1993, he had cervical compression and spondylosis with radicular symptoms to the right arm. On routine medical history report in September 1993, he also reported sinusitis, hernia, a painful or "trick" shoulder or elbow, and broken bones. On examination, he reported right paresthesia of the shoulder and arms when rotating the neck to the right; the report noted osteoarthritic spurring of C5-C6-C7 with secondary radicular neuropathy. In January 1994, he presented with complaints of tightness in the chest and dizziness for the past 2 weeks. A cardiac etiology was negative. His blood pressure was 145/82. On an October 1995 retirement physical examination report, sinusitis was described as an ongoing problem, and he had positive maxillary sinus tenderness on the right. He also was noted as having a history of dizziness and fainting with an inner ear problem that first happened after knee surgery and that had been recurring from time to time since then; Dramamine helped relieve symptoms, and the condition was not getting worse but occasionally would occur. The veteran also gave a history of degenerative joint disease of multiple joints. As to his shoulders, he said he had nightime discomfort, and he said he did traction exercises for the problem. His blood pressure was 126/80. The veteran also described having sinusitis. He was diagnosed with clinical sinusitis in March 1996. Blood pressure at that time was 137/79. In April 1996, he complained of numbness on the arms and legs, with a history of similar problems diagnosed as degenerative joint disease of the cervical and lumbar spines. Blood pressure was 120/72. The veteran was released from active duty at the end of August 1996. In September 1996 and later, the veteran filed claims for service connection for multiple conditions. The veteran had various VA examinations in November 1996. He complained of decreased bilateral hearing and tinnitus as well as dizziness; he denied vertigo. Diagnoses were pre- syncopal instability of gait and bilateral tinnitus; hearing loss needed to be ruled out. An audiology test showed hearing of both ears was within normal limits, although tinnitus was diagnosed. The veteran gave a history of tinnitus beginning in service. On another examination that month, he reported nose and sinus symptoms (nasal blockage, drainage, and pain); diagnoses included saddle nose external nasal deformity, nasal septal deformity (for which surgery was recommended), and vasomotor rhinitis. He also underwent a VA hypertension examination in November 1996. Blood pressure was measured as 135/65, 134/66, and 133/67. There was a diagnosis of labile arterial hypertension. A December 1996 VA orthopedic examination focused on conditions not involved in the service connection claims now on appeal. In March 1997, the veteran reported several weeks of sinus and head congestion with clear drainage; the assessment was clinical allergic rhinitis/sinusitis. Probably labyrinthitis was noted in March 1997. Blood pressure that month was measured at 134/72. In April and May 1997, he was seen for right shoulder complaints. In April 1997, he was diagnosed with sinus congestion. Vertigo and labyrinthitis were noted in April 1997, with a history dating back to physical therapy after right knee surgery in 1984; since 1993, his symptoms had reportedly been daily but intermittent, with nausea. The diagnosis was benign paroxysmal positional vertigo. Blood pressure in April 1997 measured 140/87. A past medical history of sinusitis was noted in May 1997, along with assessments of dyspepsia and degenerative joint disease. A May 1997 VA upper gastrointestinal series with barium swallow, to evaluate dyspepsia, showed a normal esophagus without evidence of hiatal hernia or gastroesophageal reflux; his gallbladder was also normal. Lay statements from May, July, and August 1997 refer to various problems experienced by the veteran, including stomach, sinus, and shoulder problems Outpatient records show the veteran was treated for subacromial bursitis of the left shoulder in August 1997. In September 1997, he was seen for a history of dyspepsia and flatulence that was not relieved by Tagamet; he also had been taking Tums for more than 10 years. He had a history of positive h. pylori. He also had had anemia. His blood pressure was 138/72. Impressions were gastroesophageal reflux disease (GERD) and thrombocytosis; peptic ulcer disease and h. pylori needed to be ruled out. On VA examination of the nose and sinuses in October 1997, the veteran reported nose and sinus symptoms for the past 25 years, with complaints of nasal drainage and blockage. The diagnoses were nasal airway obstruction secondary to nasal septal deformity and hypertrophy of nasal turbinates, and vasomotor rhinitis. The veteran was examined by the VA in October 1997 with complaints of reflux epigastric burning sensation, heartburn, and regurgitation when bending. Blood pressure was 136/76. Pertinent diagnoses were gastritis by h. pylori infection, essential thrombocytosis with anemia, and benign paroxysmal positional vertigo. He was treated for vasomotor rhinitis in November 1997, with complaints of nasal drainage, congestion, and post-nasal drip; his blood pressure at that time was 152/76. On treatment in December 1997 for allergic rhinitis, his blood pressure was 140/84. On VA examination in December 1997, he reported bilateral tinnitus for more than 20 years, hearing loss for 10 years, and disturbance of balance since 1984; he described exposure to loud noises. The diagnoses were bilateral tinnitus, and benign paroxysmal positional vertigo; hearing loss needed to be ruled out. VA examination in December 1997 revealed no sinusitis, although there was nasal deformity, with a saddle nose and a nasal septal deformity. On VA examination of the heart and of hypertension in January 1998, it was noted that he had dizziness, lightheadedness, and loss of balance during moments; it was also noted that he had a prior diagnosis of benign paroxysmal positional vertigo, treated with meclizine. The veteran reported having had elevated blood pressure for a period of one week, but that he was never treated for this problem. In pertinent part, the diagnosis was labile arterial hypertension not on treatment at this time. On VA audiological examination in January 1998, he reported some noise exposure during service, with onset of tinnitus during service; the symptoms were constant and bilateral, but more so in the left ear. His hearing was within normal limits. On VA respiratory examination in January 1998, blood pressure was 152/74. On a VA orthopedic examination in January 1998, the veteran had complaints of multiple joints including both shoulders. There were findings and an impression of bilateral shoulder impingement syndrome; X-rays of the shoulders reportedly showed no significant bony abnormality; and the examiner recommended treatment for the problem. On VA examination in February 1998, he reported daily symptoms with dyspepsia, regurgitation, and heartburn. He was diagnosed with gastritis due to helicobacter pylori, as well as status post left inguinal herniorrhaphy, small right inguinal hernia, and normocytic, normochromic anemia. Other tests showed mild obstructive pulmonary disease. A February 1998 upper gastrointestinal endoscopy for evaluation of GERD-like symptoms found mild esophagitis and a hiatal hernia; h. pylori gastritis needed to be ruled out. A March 1998 treatment note for lumbar spine symptoms indicated that he had gastrointestinal distress. His blood pressure was 146/78. On treatment for an elbow problem in August 1998, his blood pressure was 136/72. On VA examination in April 2000, the veteran complained of waking up at night due to a burning sensation in the chest and of regurgitation on bending. The diagnosis was hiatal hernia with gastroesophageal reflux disorder (GERD) and mild gastritis with h. pylori. The examiner commented that the h. pylori did not cause a hiatal hernia and reflux; the h. pylori causes gastritis, and reflux into the esophagus causes esophagitis. The examiner indicated that the hiatal hernia is an anatomical problem not due to h. pylori; it can have positive h. pylori, and exacerbation of the abdominal symptoms can occur because of this. A June 2001 VA progress note refers to diagnoses of degenerative joint disease, hiatal hernia, gastroesophageal reflux disease, and other conditions. II. Analysis Through discussions in correspondence, the RO rating decisions, the statements of the case, and the supplemental statements of the case, the VA has informed the veteran of the evidence necessary to substantiate his claims for service connection. He has been informed of his and the VA's respective responsibilities for providing evidence. Pertinent records and examinations have been obtained. The notice and duty to assist provisions of the law are satisfied. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159; see Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service connection may be granted for disability due to a disease or injury which was incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection will be rebuttably presumed for certain chronic diseases, including hypertension and arthritis, which are manifest to a compensable degree within the year after active service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Where a condition noted during service is not shown to be chronic at that time, service connection may be established by a showing of continuity of symptomatology after service. 38 C.F.R. § 3.303(b). Service connection may be granted for a condition first diagnosed after service when all the evidence, including that pertinent to service, indicates the condition was incurred in service. 38 C.F.R. § 3.303(d). With regard to the claim for service connection for hiatal hernia and esophagitis, it is noted that the veteran had upper gastointestinal symptoms/indigestion during and since service. He is already service connected for helicobacter pylori. Subsequent to service, studies led to a diagnosis of hiatal hernia and esophagitis, which may explain some of his symptoms. Although such condition was not diagnosed until after service, there is sufficient continuity of symptomatology to trace the condition to service onset. With application of the benefit-of-the-doubt rule, 38 U.S.C.A. § 5107(b), the Board finds that a hiatal hernia and esophagitis began during active duty. The condition was incurred in service, warranting service connection. With regard to sinusitis, the veteran had several complaints involving sinus tenderness with congestion and drainage during service. At his retirement, sinusitis was described as being an ongoing problem. There are also post-service findings of sinusitis. The evidence shows continuity of symptomatology of this condition since service. The Board finds that sinusitis began during active duty. The condition was incurred in service, warranting service connection. Hypertension means persistently high blood pressure. Various criteria for what is considered elevated blood pressure have been suggested, and according to some medical authorities the threshold is a systolic pressure of 140 and a diastolic pressure of 90. Dorland's Illustrated Medical Dictionary 635 (26th ed. 1981). The evidence shows that several recorded instances of elevated blood pressure during service, but there was no diagnosis of persistently high blood pressure or essential hypertension. After service, labile hypertension has been diagnosed twice on examination. This means the veteran's history of intermittent high blood pressure has been noted, but he does not currently have the chronic disability of essential hypertension. As the claimed disability of essential hypertension is not currently shown, there is no basis for service connection, and this claim must be denied. See Degmetich v. Brown, 104 F. 3d 1328 (1997). If in the future the veteran is diagnosed with persistent essential hypertension, he can apply to the RO to reopen this claim for service connection. The service medical records contain some references to left shoulder problems, including the history given by the veteran at his retirement examination. There are post-service medical findings of bursitis and impingement syndrome of the left shoulder, and there appears to be adequate continuity of symptomatology to trace the current problem to service onset. With application of the benefit-of-the-doubt rule, 38 U.S.C.A. § 5107(b), the Board finds that a left shoulder disability began during active duty. The condition was incurred in service, warranting service connection. With regard to tinnitus, the veteran has a demonstrated history of exposure to loud noises during his service. Soon after service, he reported and was diagnosed with tinnitus which reportedly began in service. After reviewing all the evidence, and applying the benefit-of-the-doubt rule (38 U.S.C.A. § 5107(b)), the Board finds that the veteran's current tinnitus began in service. Tinnitus was incurred in service, warranting service connection. With regard to labyrinthitis, the veteran states that he first started experiencing dizziness after knee surgery in service. There are diagnoses of benign labyrinthitis during service, associated with dizziness or nausea, as well as an inner ear problem. After service, the condition has been diagnosed as benign paroxysmal positional vertigo. After reviewing all the evidence, and applying the benefit-of-the- doubt rule (38 U.S.C.A. § 5107(b)), the Board finds that the veteran's benign paroxysmal positional vertigo began in service. Benign paroxysmal positional vertigo, claimed as labyrinthitis, was incurred in service, warranting service connection. ORDER Service connection for hiatal hernia and esophagitis is granted. Service connection for sinusitis is granted. Service connection for hypertension is denied. Service connection for a left shoulder disorder is granted. Service connection for tinnitus is granted. Service connection for benign paroxysmal positional vertigo, claimed as labyrinthitis, is granted. ____________________________________________ L.W. TOBIN Veterans Law Judge, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.