Citation Nr: 0811586 Decision Date: 04/08/08 Archive Date: 04/23/08 DOCKET NO. 04-30 066 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUES 1. Entitlement to service connection for nasopharyngeal cancer, to include as due to exposure to Agent Orange. 2. Entitlement to service connection for left ear disorder, including hearing loss, to include as secondary to nasopharyngeal cancer. 3. Entitlement to service connection for dry mouth and throat, and dysphagia, to include as secondary to nasopharyngeal cancer. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. J. Drucker, Counsel INTRODUCTION The veteran had active military service from July 1967 to May 1970 and from September 1970 to September 1972, including service in the Republic of Vietnam. This matter initially came to the Board of Veterans' Appeals (Board) on appeal from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Manchester, New Hampshire. In May 2004, the veteran testified during a personal hearing at the RO and a transcript of that hearing is of record. In July 2006, the Board remanded the veteran's case to the RO for further development. In January 2008, the veteran submitted a signed request to testify during a hearing conducted via video conference with a Veterans Law Judge but, in a March 2008 signed statement, he withdrew that request. Therefore, the Board is of the opinion that all due process requirements were met regarding the veteran's hearing request. FINDINGS OF FACT 1. The objective and competent medical evidence demonstrates that it is as likely as not that the veteran has nasopharyngeal cancer due to his active military service, including exposure to Agent Orange. 2. The objective and competent medical evidence of record demonstrates that it is as likely as not that the veteran has a left ear disorder, including middle ear effusion, intermittent tinnitus, ear blockage, and possibly worsened hearing loss, due to radiation therapy and chemotherapy treatment for nasopharyngeal cancer. 3. The objective and competent medical evidence of record demonstrates that it is as likely as not that the veteran has dysgeusia (loss of taste), and dry nose and throat symtoms due to radiation therapy and chemotherapy treatment for nasopharyngeal cancer. CONCLUSIONS OF LAW 1. Resolving doubt in the veteran's favor, nasopharyngeal cancer was incurred during active military service, including exposure to Agent Orange. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 5103-5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2007). 2. Resolving doubt in the veteran's favor, the veteran's current left ear disorder, including middle ear effusion, intermittent tinnitus, ear blockage, and hearing loss, is proximately due to, the result of, or aggravated by radiation therapy and chemotherapy treatment for his service-connected nasopharyngeal cancer. 38 U.S.C.A. §§ 1110, 5103-5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2007); Allen v. Brown, 7 Vet. App. 439 (1997). 3. Resolving doubt in the veteran's favor, the veteran's current dysgeusia, and dry nose and throat symtoms, are proximately due to, the result of, or aggravated by radiation therapy and chemotherapy treatment for his service-connected nasopharyngeal cancer. 38 U.S.C.A. §§ 1110, 5103-5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2007); Allen v. Brown, 7 Vet. App. 439 (1997). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist In November 2000, the President signed into law the Veterans Claims Assistance Act of 2000 (VCAA), which substantially amended the provisions of Chapter 51 of Title 38 of the United States Code, concerning the notice and assistance to be afforded to claimants in substantiating their claims. 38 U.S.C.A. § 5103 (West 2002 & Supp. 2007). In view of the favorable disposition of this appeal, discussed below, we find that VA has satisfied its duty to assist the veteran in apprising him as to the evidence needed, and in obtaining evidence pertaining to his claims, under the VCAA. Also, during the pendency of this appeal, on March 3, 2006, the United States Court of Appeals for Veterans Claims (hereinafter referred to as "the Court") issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom Hartman v. Nicholson, 483 F.3d 1311 (Fed Cir. 2007), that held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) applied to all five elements of a service connection claim. Id. In a July 2006 letter, the RO provided the veteran with notice consistent with the Court's holding in Dingess. Furthermore, in the instant case, although the veteran's service connection claims are being granted, no disability ratings or effective dates will be assigned and, as set forth below, there can be no possibility of prejudice to the veteran. As set forth herein, no additional notice or development is indicated in the veteran's claims. The RO will again provide appropriate notice as to the rating criteria and effective dates to be assigned prior to the making of a decision on these matters. It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court held that a veteran need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. II. Factual Background and Legal Analysis The veteran, who served in Vietnam during the Vietnam War, has alleged entitlement to service connection for nasopharyngeal cancer that he asserts is secondary to Agent Orange exposure. According to 38 U.S.C.A. § 1110, a veteran is entitled to disability compensation for disability resulting from personal injury or disease incurred in or aggravated by service. In the case of malignant tumors, service incurrence may be presumed if the disease is manifested to a compensable degree within one year of service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.303, 3.307, 3.309. In addition to the forgoing, the Board observes that, if a veteran was exposed to an herbicide agent during active military, naval, or air service, certain diseases shall be service connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied, including: respiratory cancers (cancer of the lung, bronchus, larynx, or trachea) and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). The diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more any time after service, except that chloracne and porphyria cutanea tarda shall have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii). The Secretary of the Department of Veterans Affairs has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See, e.g., Notice, 72 Fed. Reg. 32,395-407 (June 12, 2007); Notice, 68 Fed. Reg. 27,630-41 (May 20, 2003), and Notices at 61 Fed. Reg. 57,586- 589 (1996); 64 Fed. Reg. 59,232-243 (1999); and 67 Fed. Reg. 42,600-608 (June 24, 2002). See also "Veterans and Agent Orange: Update 2006 (2007)" (indicating that there was inadequate or insufficient evidence to determine whether an association existed between exposure to chemicals of interest and cancers of the oral cavity, pharynx, or nasal cavity). Notwithstanding the foregoing, regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); Ramey v. Brown, 9 Vet. App. 40, 44 (1996), aff'd sub nom. Ramey v. Gober, 120 F.3d 1239 (Fed. Cir. 1997), cert. denied, 118 S. Ct. 1171 (1998). See Brock v. Brown, 10 Vet. App. 155, 160-61 (1997). In other words, presumption is not the sole method for showing causation in establishing a claim for service connection as due to herbicide exposure. Thus, service connection may be presumed for residuals of Agent Orange exposure by showing two elements. First, it must be shown that the veteran served in the Republic of Vietnam during the Vietnam era. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307(a)(6). Second, the veteran must have been diagnosed with one of the specific diseases listed in 38 C.F.R. § 3.309(e), or a nexus between the currently diagnosed disability and service must otherwise be established. See Brock v. Brown, 10 Vet. App. at 162. The first question is whether the veteran was exposed to Agent Orange during service. The above-described presumptions apply only to veterans who actually served in Vietnam (although there is no minimum time frame provided by the law). In this case, the RO accepted and the Board has no reason to doubt, that he served in Vietnam during the Vietnam era; thus, he is presumed to have been exposed to Agent Orange during such service. Service medical records are not referable to complaints or diagnoses of, or treatment for, nasopharyngeal cancer. Post service, audiograms from the Naval Medical Center, dated from 1983 to 1996, reflect some left ear hearing loss. VA medical records, dated during 2002 and 2003, indicate that the veteran experienced left ear fullness, pain and hearing loss in September and October 2002, with left-sided facial pain, numbness, dysphasia, mild pain on swallowing, and epistaxis. Results of a biopsy performed in April 2003 revealed squamous cell carcinoma of the nasopharynx. A June 2003 VA medical record indicates the veteran was seen in the outpatient clinic by the Chief of Hematology/Oncology at the VA medical faculty. The veteran's initial symtoms of left ear blockage were noted and that he was finally found to have a visibly abnormal ear tube blocked by a tumor. Treatment involved radiation and chemotherapy. The record indicates that the veteran's past medical history included left ear hearing problems since service in Vietnam for which service connection was denied in March 1997. In a June 2003 signed statement, the Chief of Hematology/Oncology at the VA medical center, noted above, said that the veteran was diagnosed with nasopharyngeal carcinoma that was an aero digestive tract carcinoma for which he was undergoing radiation therapy and chemotherapy. The VA physician said the veteran requested the doctor to mention that his nasopharyngeal carcinoma was a condition that should be included as an Agent Orange associated malignancy since it was included in the same diagnostic category as the other respiratory tract cancers that were specifically mentioned in VA regulations section 38 C.F.R. § 3.309(e). An October 2003 private treatment record from a radiation oncologist reflects the veteran's report of dry mouth with less saliva that he was used to, but he had some saliva production and the physician speculated that the veteran's sense of taste would begin to return during the next few months. It was noted that the veteran experienced bilateral tinnitus, that he had to some degree since his return from Vietnam, and it worsened, probably as a result of the cisplatin (chemotherapy medication) and high dose radiation therapy to his nasopharynx. In October 2003, the veteran underwent VA examination. According to the examination report, nasopharyngeal cancer was diagnosed in May 2003. It was noted that, prior to that, the veteran complained of epistaxis, on the left side of his nose, as well as decreased hearing in his left ear. Subsequently, a computed tomography (CT) disclosed a nasopharyngeal mass compressing the veteran's Eustachian tube and creating an effusion in his left ear. A biopsy of the lesion revealed the presence of a squamous cell carcinoma, moderately to poorly differentiated. A drain was inserted in the veteran's left ear to relieve the pressure from the effusion of the middle ear. The cancerous growth was treated with radiation treatments and chemotherapy that ended in July 2003. He experienced weight loss during the treatment. Further, the veteran said he experienced a dry throat and dry mouth, with some problems swallowing certain dry foods and some intolerance for pepper and some other spices. He had very little discomfort in his throat and little-to-no discomfort swallowing. However, he lacked an appetitie and said nothing actually tasted good. His weight was stable over the summer and he had no gastrointestinal problems. He had no further nosebleeds. He still had the drainage tube in is left ear, and said his hearing was still somewhat decreased. He denied having vertigo or headaches. The veteran said he continued to work full time but changed jobs, doing office work. He was medically disqualified to do his regular job apparently due to his diagnosis. It was noted that he was a nonsmoker. Upon clinical examination, the diagnoses were squamous cell carcinoma of the nasopharynx treated with radiation and chemotherapy with reasonably good prognosis, residuals from radiation therapy, generally dry mouth and throat and dysphagia, and some decreased hearing on the left side from middle ear disease secondary to the effusion with some permanent hearing loss. In an April 2004 private treatment record, prepared by J.M. O'D., M.D., it was noted that the veteran was seven months status post treatment for a stage 2B squamous cell carcinoma of the nasopharynx treated with chemotherapy and radiation. Dr. O'D. said that he had a lengthy discussion with the veteran regarding whether the nasopharynx was considered part of the respiratory tract. In response to the veteran's query regarding whether the veteran's nasopharynx carcinoma was casually related to Agent Orange exposure, Dr. O'D. said it was not his area of expertise but, if Agent Orange was associated with respiratory tract carcinomas, "certainly the nasopharynx [was] part of the upper respiratory tract". In an April 2004 signed statement, the Chief of Hematology Oncology at the VA medical facility said he reviewed the veteran's case and concluded that it was "very likely" that exposure to Agent Orange "played a role" in the veteran's subsequent development of nasopharyngeal cancer. The physician referenced a VA Agent Orange Brief that indicated respiratory cancers were considered medical conditions associated with Agent Orange. According to this medical specialist, the nasopharynx was considered part of the respiratory tract and was classified as part of the same head and neck region as the larynx. The doctor said that laryngeal cancer, according to VA's guidelines, was a condition associated with Agent Orange. The VA physician stated that it "seems patently obvious to me that nasopharyngeal cancer should also be included in the same way". The doctor further stated that it was now known that this malignancy was being observed with increased frequency in Vietnam veterans and that was most likely due to Agent Orange. According to the VA physician, this was much the same logic that led to chronic lymphocytic leukemia being including under the broader heading of non-Hodgkin's lymphoma. During his May 2004 personal hearing at the RO, the veteran testified to his heavy exposure to Agent Orange while serving in Vietnam. It was noted that he experienced loss of taste and dry mouth due to his radiation treatment for his nasopharyngeal cancer (see hearing transcript, at pages 13- 14). In a May 2006 signed statement, the VA Chief of Hematology Oncology opined that "it is more likely than not that [the veteran's] exposure to Agent Orange and dioxins stemming from his military service in Vietnam was a proximal cause of his nasopharyngeal cancer". The medical specialist said that inhaled herbicides and dioxins were known to permeate the respiratory tract that included the nasal pharynx. Since lung and bronchial cancers as well as the larynx and trachea were considered related to service in terms of Agent Orange, the VA physician said it was "only logical" that the nasopharynx should be included as well. Pursuant to the Board's June 2006 remand, in an August 2006 medical opinion, the VA Chief of Hematology Oncology reviewed the veteran's medical records. He said that he knew the veteran well and felt that the veteran was heavily exposed to Agent Orange in service, and subsequently diagnosed with nasopharyngeal carcinoma, that was a squamous cell carcinoma. The VA medical specialist opined that "it is more likely than not" that this carcinoma of the nasopharynx, which is part of the respiratory tract, is causally related to his exposure to herbicide, specifically Agent Orange, during his Vietnam service. According to the VA oncologist, VA recognized respiratory cancers of the lungs, larynx, trachea, and bronchus as presumptive exposure to Agent Orange for service connection purposes. Thus, if the veteran was service-connected for squamous cell carcinoma of the lungs, larynx, trachea, or bronchus then, by the precedent that the VA already set, nasopharynx carcinoma should be included. The physician said it was "only the rarity of this diagnosis that has prevented it from being included with the other respiratory cancers." The VA physician reiterated that, in his opinion, it was much more likely than not that the veteran's nasopharyngeal cancer should be considered service- connected as due to exposure to Agent Orange. In September 2006, the veteran underwent a VA general medical examination performed by an urgent care physician. According to the examination report, the examiner reviewed the veteran's medical records and performed a clinical examination. The veteran complained of near constant tinnitus and decreased left ear hearing that started in 2002. He also reported loss of taste. The examiner noted an audiology appointment in the VA outpatient clinic in October 2006, although that report is not currently in the claims file. In this examiner's opinion, the veteran's nasopharyngeal cancer was at least as likely as not related to his exposure to Agent Orange. She said she reviewed the veteran's records, including the medical opinion from the VA chief of hematology/oncology and agreed with his opinion, including his 2006 opinion. She cited medical literature to support her opinion, including results from an epidemiology study performed by Richard Clapp that noted the increased incidence of nasal/nasopharyngeal cancer and oral cancer in Vietnam veterans. The VA examiner said that it also made "medical sense that the SAME type of cells lining the pharynx and the larynx would be at least as likely as not to have the SAME reaction to a given toxic agent such as [A]gent [O]range". Also in September 2006, the veteran underwent a VA examination performed in the ear, nose, and throat (ENT) clinic of a VA outpatient medical facility. It was noted that the veteran experienced left middle ear effusion starting in September or October 2002 and was diagnosed with nasopharyngeal carcinoma in the spring of 2003. He had squamous cell carcinoma of the nasopharynx, treated with radiation and chemotherapy. The veteran experienced left intermittent tinnitus and ear blockage. He also described dysgeusia and dry nose and mouth. Upon examination and review of the veteran's medical records, the VA examiner diagnosed nasopharyngeal carcinoma, with no evidence of disease following chemotherapy and radiation therapy. The VA examiner said that the etiology of nasopharyngeal carcinoma was not always determined. There was an association with Epstein-Barr virus. Many cases were also idiopathic. Smoking and/or alcohol could be considered carcinogen factors. It was noted that the veteran reported no significant smoking history but was a heavy alcoholic. The VA examiner stated that Agent Orange was well known to cause respiratory tract carcinomas such as laryngeal, tracheal, or bronchia carcinoma. There was no medical literature that linked nasopharyngeal carcinoma with Agent Orange. Then the VA examiner said that "[i]t is conceivable" that Agent orange may cause nasopharyngeal carcinoma since the nasopharynx is part of the respiratory tract and "[t]his hypothesis is very plausible" but not proven as yet. Therefore, "even though it is highly likely that the patient's nasopharyngeal carcinoma was caused by exposure to Agent Orange", such a connection cannot be established with certainty until VA does a study or changed policies to connect nasopharyngeal carcinoma with Agent Orange exposure. Otherwise the connection is anecdotal. The VA examiner further stated that the veteran's left ear symtoms, dysgeusia and dry nose and throat symtoms were caused by the radiation therapy and chemotherapy for the nasopharyngeal carcinoma. A. Service Connection for Nasopharyngeal Cancer As noted above, diseases or disorders that have been positively associated with Agent Orange do not include nasopharyngeal cancer and, accordingly, the veteran is not entitled to a presumption of service connection under the statutes and regulations. Thus, even conceding the veteran's exposure to Agent Orange, nasopharyngeal cancer is not a disorder that is presumptively service connected on the basis of herbicide exposure. See 38 U.S.C.A. § 1154(b) (West 2002); 38 C.F.R. §§ 3.307, 3.309. However, as also noted above, a claimant is not precluded from presenting proof of direct service connection between a disorder and exposure to Agent Orange, even if the disability in question is not among statutorily enumerated disorders which are presumed to be service-related, the presumption not being the sole method for showing causation. See Combee v. Brown, supra. Hence, the appellant may establish service connection for nasopharyngeal cancer by presenting competent evidence which shows that it is as likely as not that the disorder was caused by in-service Agent Orange exposure. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 3.303; Gilbert v. Derwinski, 1 Vet. App. at 49. As the medical evidence of record shows, the veteran was diagnosed with squamous cell carcinoma of the nasopharyngeal in 2003, nearly thirty years after his discharge. Based on the above medical opinions, which are supported by the evidence of record, the Board finds that the evidence is equally balanced as to whether the veteran has nasopharyngeal cancer as a result of service. In his April 2004 and May and August 2006 written statements, the Chief of Hematology Oncology at a VA medical facility, concluded that it was as likely as not that the veteran had nasopharyngeal cancer due to exposure to Agent Orange. The VA medical specialist opined that "it is more likely than not" that the veteran's carcinoma of the nasopharynx, that was part of the respiratory tract, was causally related to his exposure to herbicide, specifically Agent Orange, during his Vietnam service. Furthermore, the September 2006 VA examiner agreed with the 2006 opinion of the VA Chief of Hematology Oncology and buttressed her opinion with citations to pertinent medical literature. See Combee v. Brown, supra. The Board recognizes that the September 2006 VA ENT examiner said that the etiology of nasopharyngeal carcinoma was not always determined and noted an association with Epstein-Barr virus, although there is no indication that the veteran had this virus. The doctor also said many cases are idiopathic. While the ENT examiner noted that smoking and/or alcohol may be considered carcinogen factors, it was also noted that the veteran did not have a significant smoking history, although he was a heavy alcoholic. Significantly, however, the VA examiner also said that "it was conceivable" that Agent Orange may cause nasopharyngeal carcinoma, that this hypothesis "is very plausible" but not yet proven, and that "it is highly likely that [the veteran's] nasopharyngeal carcinoma was caused by exposure to Agent Orange" but further study by VA was needed to establish the connection with certainty. In light of the foregoing, the Board finds that the evidence of record is consistent with the veteran's contentions. The preponderance of the objective and competent medical evidence of record supports the veteran's claim. Accordingly, in resolving doubt in the veteran's behalf, the Board concludes that service connection for nasopharyngeal cancer is in order. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. B. Service Connection for Left Ear Hearing Loss, Dry Mouth, Throat and Dysphagia Secondary service connection may be granted for a disability that is proximately due to, or the result of, a service- connected disease or injury. 38 C.F.R. § 3.310(a). With regard to the matter of establishing service connection for a disability on a secondary basis, the Court has held that there must be evidence sufficent to show that a current disability exists and that the current disability was either caused or aggravated by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Additionally, when aggravation of a non-service-connected disability is proximately due to or the result of a service- connected condition, such disability shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Id.; see also 38 C.F.R. § 3.310(b) (2007). The veteran has further contended that service connection should be granted for left ear hearing loss, dry mouth and throat, and dysphagia, due to his nasopharyngeal cancer. The veteran's audiograms dated prior to 1996 reflect left ear hearing loss consistent with 38 C.F.R. § 3.385 (2007) (for the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies at 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies at 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent). The audiograms show that, at 4000 Hertz, the veteran's left ear hearing was 40 decibels or greater in 1996. As the recent medical evidence of record shows, in October 2003, the veteran reported left ear effusion, with a dry mouth and throat, and some problems swallowing dry foods, and said nothing tasted good. The VA examiner at that time diagnosed residuals from radiation therapy- generally dry mouth and throat and dysphagia and some decreased hearing on the left side from middle ear disease secondary to the effusion with some permanent hearing loss. During his September 2006 VA ENT examination, the veteran reported having left middle ear effusion since 2002 and, in September 2006, continued to experience left intermittent tinnitus with left intermittent ear blockage. He also experienced dysgeusia and dry nose and mouth. In September 2006, the VA ENT examiner said that the veteran's left ear symtoms, dysgeusia and dry nose and throat were caused by the radiation therapy and the chemotherapy for the nasopharyngeal cancer. In light of the foregoing, the Board finds that the evidence of record is consistent with the veteran's contentions. See 38 C.F.R. § 3.310(b); Allen, supra. Accordingly, in resolving doubt in the veteran's behalf, the Board concludes that service connection for a left ear disorder, including middle ear effusion, intermittent tinnitus, ear blockage, and hearing loss, and dysgeusia and dry nose and throat symtoms, is in order. 38 C.F.R. §§ 3.102, 3.310(b); Allen, supra. While the October 2006 VA audiology note is not in the file, we take this grant to include any worsened hearing loss evidenced in the clinical records. ORDER Service connection for nasopharyngeal cancer, to include as due to exposure to Agent Orange, is granted. Service connection for a left ear disorder, including middle ear effusion, intermittent tinnitus, ear blockage, and hearing loss, to include as due to nasopharyngeal cancer, is granted. Service connection for dysgeusia, and dry nose and throat symtoms, to include as due to nasopharyngeal cancer, is granted. ____________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs