Citation Nr: 1219620 Decision Date: 06/05/12 Archive Date: 06/13/12 DOCKET NO. 08-33 078 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to a rating in excess of 30 percent for status post nasal bone fracture with deformity, total bilateral nasal obstruction, and profound vasomotor reaction with bilateral polyps. 2. Entitlement to an initial rating in excess of 10 percent for sinusitis with diminished sense of smell and taste. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disability. 4. Entitlement to an effective date earlier than March 9, 2004, for the assignment of a 30 percent rating for status post nasal bone fracture with deformity, total bilateral nasal obstruction, and profound vasomotor reaction with bilateral polyps. REPRESENTATION Appellant represented by: Darla J. Lilley, Attorney at Law ATTORNEY FOR THE BOARD David S. Ames, Counsel INTRODUCTION The Veteran served on active duty from July 1978 to July 1981. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office in Jackson, Mississippi (RO). The issues of entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) and entitlement to an effective date earlier than March 9, 2004, for the assignment of a 30 percent rating for status post nasal bone fracture with deformity, total bilateral nasal obstruction, and profound vasomotor reaction with bilateral polyps, are REMANDED to the RO via the Appeals Management Center, in Washington, D.C. In October 2007, the Veteran's representative raised the issue of entitlement to service connection for rhinitis. In January 2008, the Board referred that issue to the RO for appropriate action, but evidence of record does not show that any action has been taken on the claim. In addition, in October 2009, the Veteran's representative raised the issues of entitlement to service connection for a neurological disorder, to include as secondary to the Veteran's service connected nasal and sinusitis disorders, and entitlement to service connection for a psychological disorder, to include as secondary to the Veteran's service connected nasal and sinusitis disorders. None of those issues has been developed for appellate review and they are therefore referred to the RO for appropriate disposition. FINDINGS OF FACT 1. The evidence of record shows that the Veteran's sinusitis is manifested by no more than six non-incapacitating episodes per year. 2. The medical evidence of record shows that the Veteran's nasal bone fracture with deformity is manifested by bilateral total nasal obstruction, tenderness, diminished sense of taste, diminished sense of smell, abnormal voice, nasal polyps, abnormal turbinates, and significant nasal deformity. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for sinusitis with diminished sense of smell and taste have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.97, Diagnostic Code 6513 (2011). 2. The criteria for a rating in excess of 30 percent for status post nasal bone fracture with deformity, total bilateral nasal obstruction and profound vasomotor reaction with bilateral polyps, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.97, Diagnostic Code 6522 (2011). 3. The criteria for a separate rating of 10 percent, but not higher, for nasal deformity have been met. 38 U.S.C.A. § 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.97, Diagnostic Code 6504 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. § 3.159 (2011); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from a notice error, rather than on VA to rebut presumed prejudice. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The Board finds that any defect with regard to the timing or content of the notice to the Veteran is harmless because of the thorough and informative notices provided throughout the adjudication and because the Veteran had a meaningful opportunity to participate effectively in the processing of the claim with an adjudication of the claim by the RO subsequent to receipt of the required notice. The record does not show prejudice to the Veteran, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the Veteran was notified in letters dated in August 2004, March 2006, August 2008, and November 2009. The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing that an error is harmful, or prejudicial, falls upon the party attacking the agency's determination); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board considers it significant that the subsequent statements made by the Veteran and his representative suggest actual knowledge of the elements necessary to substantiate the claim. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what is necessary to substantiate a claim). Thus, VA has satisfied its duty to notify the Veteran and had satisfied that duty prior to the adjudication in the supplemental statement of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the Veteran of any evidence that could not be obtained. The Veteran has not referred to any additional, unobtained, relevant, available evidence. VA has obtained an examination with respect to the claims. Thus, the Board finds that VA has satisfied the duty to assist provisions of law. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2011). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2011). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2011). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2011); Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31 (1999). The appeal of the Veteran's sinusitis claim is based on the assignment of an initial rating following an initial award of service connection for sinusitis. Therefore, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence used to decide whether an original rating on appeal was erroneous. Fenderson v. West, 12 Vet. App. 119 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson v. West, 12 Vet. App. 119 (1999). For general increased rating claims, staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Service connection for status post fracture of the nasal bone, was granted by a February 1988 rating decision and a 0 percent rating was assigned, effective April 14, 1987, under 38 C.F.R. § 4.97, Diagnostic Code 6502. Subsequently, a January 1989 rating decision assigned a 10 percent rating, effective March 15, 1988, under 38 C.F.R. § 4.97, Diagnostic Code 6502. A November 3, 2004 rating decision then recharacterized the disability as status post nasal bone fracture with deformity, total bilateral nasal obstruction and profound vasomotor reaction with bilateral polyps, and assigned a 30 percent rating, effective March 9, 2004, under 38 C.F.R. § 4.97, Diagnostic Code 6522. Finally, service connection for sinusitis with diminished sense of smell and taste was granted by a June 2006 rating decision and a 10 percent rating was assigned, effective October 1, 1999, under 38 C.F.R. § 4.97, Diagnostic Code 6513. With respect to the issue of entitlement to a rating in excess of 30 percent for status post nasal bone fracture with deformity, the Board notes that the claim on appeal has recently been adjudicated as originating from an October 2009 claim for entitlement to an increased rating for the Veteran's nasal bone fracture disability. That claim resulted in a December 2009 rating decision, a February 2010 notice of disagreement, and an August 2011 statement of the case, with the appeal finally perfected to the Board in August 2011. However, the currently assigned 30 percent rating was originally granted by a November 2004 rating decision. In September 2005, the Veteran's representative submitted a notice of disagreement with respect to the November 2004 rating decision, and specifically appealed both the rating and the effective date assigned. Accordingly, the Board finds that the September 2005 statement from the Veteran's representative constitutes a timely notice of disagreement with the 30 percent rating assigned for status post nasal bone fracture with deformity, total bilateral nasal obstruction, and profound vasomotor reaction with bilateral polyps in November 2004. 38 C.F.R. § 20.201 (2011). As discussed below, the Veteran has not since been provided with a statement of the case with respect to the earlier effective date aspect of the claim, and therefore that aspect of the claim must be remanded. Manlincon v. West, 12 Vet. App. 238 (1999). However, the increased rating aspect of the claim has since been readjudicated by the RO in the December 2009 rating decision and the August 2011 statement of the case, and the Veteran perfected an appeal as to the issue in August 2011. Accordingly, the Board will proceed with adjudication of the Veteran's increased rating claim as it originated with the November 2004 rating decision. A May 1999 private medical report stated that, on physical examination, there was minimal left maxillary tenderness; postnasal drip; and enlarged turbinates, bilaterally. The Veteran's nose and throat were otherwise unremarkable. The Veteran was given medication for sinusitis and allergies. In a second May 1999 private medical report, the Veteran complained of a persistent cough and rhinorrhea, but reported improvement. On physical examination, there was mild right maxillary tenderness; postnasal drip; and enlarged turbinates, bilaterally. The Veteran's nose and throat were otherwise unremarkable. The impression was resolving sinusitis and persistent allergic rhinitis. The Veteran was given medication for sinusitis and allergies. In a June 1999 private medical report, the Veteran complained of some right maxillary tenderness, but with diminished coughing, nose dripping, and nasal symptomatology. On physical examination there was mild right maxillary tenderness; postnasal drip; enlarged turbinates, greater on the left than the right; and allergic shiners. The Veteran's nose and throat were otherwise unremarkable. The impression was mildly persistent sinusitis although much improved over last visit, and persistent allergic rhinitis. The Veteran was given medication for sinusitis and allergies. In an August 1999 private medical, the Veteran reported not experiencing any symptoms other than a runny nose and a cough. On physical examination there was bilateral maxillary tenderness and postnasal drip. The impression was allergic rhinitis/sinusitis. In an October 1999 private medical report, the Veteran complained of a productive cough for several days. On physical examination there was right maxillary tenderness and enlarged turbinates, greater on the right than the left. The Veteran's nose and throat were otherwise unremarkable. The impression was allergic rhinitis/sinusitis. In a November 2001 VA outpatient medical report, the Veteran complained of chronic sinus problems and chronic allergies. On physical examination, the Veteran's nasal mucosa were moist and his turbinates were boggy and narrowed. There was tenderness to the sinus, maxillary, and oropharynx. No pharynx abnormalities were noted. The impression was seasonal allergies and sinus drainage. In a May 2002 VA outpatient medical report, the Veteran complained of coughing, headaches, nasal congestion, and a runny nose for the previous four days. On physical examination, the Veteran's nasal mucosa were moist and his turbinates were boggy and narrowed. There was tenderness to the sinus and maxillary. No pharynx abnormalities were noted. The impression was sinusitis, seasonal allergies, and sinus drainage. On physical examinations, VA outpatient medical reports dated in December 2002 and June 2003 noted findings that were essentially identical to those found in the May 2002 VA outpatient medical report. In an August 2003 private medical report, the Veteran complained of nasal obstruction, postnasal drainage, and a pressure sensation on his sinus area. On physical examination, the Veteran had a deviated septum with boggy turbinates, consistent with probable allergic rhinitis. There were no oral abnormalities noted, though the Veteran had postnasal drainage and there was pain to palpation of the sinus area. Computed tomography examination of the sinuses showed ethmoiditis and maxillary sinus on both sides. The examiner stated that the Veteran's allergic phenomena were not due to the accident he sustained during service, and were due to probable environmental allergic reactions. In a January 2004 VA outpatient medical report, the Veteran complained of thick green sinus drainage with sinus pain. On physical examination, the Veteran's oral cavity was normal. There was sinus tenderness with swollen erythematous sinuses noted. The impression was chronic sinusitis. In a July 2004 VA outpatient medical report, the Veteran complained of thick yellow/green sinus discharge that came and went, and fluctuating congestion and a runny nose. On physical examination, the Veteran's oral cavity was normal. There was maxillary sinus tenderness. The Veteran's nasal turbinates were swollen, boggy, and erythematous. The impression was chronic sinusitis. In an October 2004 VA nasal examination report, the Veteran complained of difficulty breathing due to a collapse of the nasal cartilage. He reported that he was a chronic, almost total mouth breather, and had a diminished sense of taste. On examination, the Veteran had an abnormal voice with a nasal quality consist with nasal obstruction. There was cartilaginous deformity of the external nasal structures with a saddle defect on the dorsum of the nose, caused by a loss of lateral and dorsal cartilage. Internally, the septum was slightly thickened, the turbinates were extremely hyperemic, and there was total obstruction of the nasal cavity, bilaterally. A watery discharge was present. The Veteran had nasal polyps, posteriorly, in each middle meatus. The sinuses did not transilluminate and there was tenderness to percussion over the maxillary sinuses. The Veteran's oral cavity, pharynx, larynx, and neck were normal. The impression was that the Veteran had a significant nasal deformity with loss of nasal cartilaginous support and formation of saddle bag deformity. There was also total bilateral nasal obstruction secondary to extreme to profound vasomotor reaction with bilateral nasal polyps, and chronic, bilateral maxillary and frontal sinus changes. In a January 2005 VA outpatient medical report, the Veteran complained of sinus pain and pressure with a yellow discharge. On physical examination, there was positive sinus pressure and tenderness. The Veteran's nasal turbinates were swollen and boggy, with noted exudate and erythema. The impression was chronic sinusitis. In a July 2005 VA outpatient medical report, the Veteran complained of allergies, recurrent sinus infection, sinus pain, and sinus pressure. On physical examination, there was positive sinus pressure. The Veteran's nasal turbinates were very swollen and boggy, with noted exudate and erythema. The impression was chronic sinusitis. In a January 2006 VA outpatient medical report, the Veteran complained of sinus pressure. On physical examination, there was positive sinus pressure. The Veteran's nasal turbinates were very swollen and erythematous. The impression was chronic sinusitis. In a July 2006 VA outpatient medical report, the Veteran complained of a sinus infection. On physical examination, there was positive sinus pressure. The Veteran's nasal turbinates were boggy. The impression was sinusitis. In a January 2007 VA outpatient medical report, the Veteran denied experiencing any sinus pain. On physical examination, the Veteran's sinuses were boggy and erythematous. The impression was chronic sinusitis. In a March 2007 VA nasal examination report, the Veteran complained of constant pain in the nasal complex area, significant recurring infections, frequent episodes of nasal discharge, diminished sense of smell, diminished sense of taste, and severe difficulty breathing through his nose. With regard to his senses of smell and taste, the Veteran reported experiencing periods when they were completely absent, though they returned at a diminished capacity below normal. On examination, the Veteran had a significant deformity of the nasal and sinus area. The nasal bones were palpable and in a normal position, however palpation caused significant pain and discomfort. At the tip of the nasal bone there was a significant drop off and depression of the soft tissues of the nasal dorsum and tip. The columella was shortened and had no cartilaginous support. The anterior portion of the nasal septal cartilage was deficient and there was significant obstruction of the external nares by collapsing of the ala, bilaterally, on breathing. Internally, the septum was deficient of cartilage anteriorly and superiorly. The turbinates were severely hyperemic. There was an almost total obstruction, bilaterally, created by the large turbinates and by the collapse of the columella and the septal tissues secondary to the cartilaginous loss. In addition, there was looseness and dysfunction of the ala due to the same reasons. Any attempt to breathe in through the nose with any force created a complete collapse and closure of the external nares. No polyps were noted, though there appeared to be some decreased illumination on the maxillary sinuses while the frontals appeared to be within normal limits. No masses or other abnormalities were palpated over any of the sinuses. The Veteran's oral cavity was normal except for some scarring in the upper external sulcus. The pharynx, larynx, and neck were all normal. In a September 2007 VA outpatient medical report, the Veteran complained of sinus headaches and a sinus infection. On physical examination, there was positive sinus pressure. The Veteran's sinuses were very large, boggy, and swollen, with erythema. The impression was chronic sinusitis and acute sinusitis. In a March 2008 VA outpatient medical report, the Veteran complained of severe sinusitis. On physical examination, there was maxillary sinus congestion. The Veteran's sinuses were large, red, and boggy. His pharynx was normal. The impression was chronic sinusitis. In an October 2008 VA outpatient medical report, the Veteran complained of sinus pain, sinus pressure, and sinus headaches. On physical examination, there was maxillary sinus tenderness and the Veteran's sinuses were large, dry, boggy, and erythematous. The impression was chronic sinusitis. In an April 2009 VA nasal examination report, the Veteran complained of difficulty breathing through his nose and repeated episodes of infections. On examination, the nasal septal cartilages appeared to have been separated from the nasal bones and were significantly depressed downward, with a step off between the two structures. The paranasal sinus structures showed tenderness over the maxillary areas on mild percussion or pressure. There was almost complete internal obstruction, bilaterally. The turbinates were extremely hyperemic, and the superior aspect of the nasal passage was narrowed by the downward collapse of the nasal cartilages. That resulted in loss of the nasal valve structure, the combination of which produced total obstruction of the nasal cavity, bilaterally. No maxillary sinus changes were noted, bilaterally. The Veteran's oral cavity, pharynx, larynx, and neck were within normal limits. In multiple private medical reports dated in May 2009 and June 2009, the Veteran complained of multiple sinus related symptoms, including sinus pain, sinus pressure, and a productive cough. In an October 2009 VA outpatient medical report, the Veteran complained of maxillary sinus congestion and sinus headaches for approximately two weeks. On physical examination, the Veteran's pharynx was within normal limits. The nasal turbinates were large and boggy with erythema and exudate. There was also maxillary facial pressure. The impression was chronic sinusitis. In a December 2009 VA outpatient medical report, the Veteran denied any sinus pain. He reported experiencing frontal headaches at times related to chronic sinusitis. On physical examination, the Veteran's oral cavity was normal. The impression was chronic sinusitis. In a September 2010 VA nose, sinus, larynx, and pharynx examination report, the Veteran complained of continuous nasal obstruction requiring continuous mouth breathing. The Veteran reported that he could not taste food well and had difficult smelling most of the time. He reported that on occasion he could get an indication of some odor, but such instances were infrequent. On examination, the Veteran was continuously mouth breathing. There was an extremely obvious deformity of the nose, with the soft tissues having all been depressed downward. The nose had also been shortened and it appeared that the soft tissue structures, including the cartilage, had been driven back up into the nose beneath the nasal bones. The soft tissues over the sinuses revealed tenderness over the maxillary sinuses, bilaterally. The frontal area was negative. Internally, the Veteran's nose was totally obstructed, bilaterally. The cartilage was distorted and the turbinates were extremely enlarged, resulting in the total obstruction. The examiner could not determine whether polyps were present or not. There was a slight watery discharge in the anterior nose, and the posterior nose could not be seen. There was bilateral sinus disease, primarily maxillary and probably ethmoids. No abnormalities of the oral cavity, pharynx, larynx, or neck were noted. In a March 2011 VA outpatient medical report, the Veteran reported experiencing maxillary sinus pressure. On physical examination, the Veteran had large, swollen, boggy sinuses and mild pharyngeal erythema. The impression was chronic sinusitis. Sinusitis The Schedule states that pansinusitis, ethmoid sinusitis, frontal sinusitis, maxillary sinusitis, and sphenoid sinusitis are rated under the General Rating Formula for Sinusitis. 38 C.F.R. § 4.97, Diagnostic Codes 6510-6514 (2011). Under the General Rating Formula for Sinusitis, a 0 percent rating is warranted for sinusitis that is detected by x-ray only. A 10 percent rating is warranted for one or two incapacitating episodes per year of sinusitis requiring prolonged, lasting four to six weeks, antibiotic treatment, or; three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 30 percent disability rating is warranted when there are three or more incapacitating episodes per year of sinusitis requiring prolonged, lasting four to six weeks, antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 50 percent rating is warranted following radical surgery with chronic osteomyelitis, or; with near constant sinusitis characterized by headaches, pain, and tenderness of the affected sinus, and prurulent discharge or crusting after repeated surgeries. 38 C.F.R. § 4.97, Diagnostic Code 6510 (2011). An incapacitating episode of sinusitis as one that requires bed rest and treatment by a physician. 38 C.F.R. § 4.97, Diagnostic Code 6510, Note (2011). The evidence of record shows that the Veteran's sinusitis is manifested by no more than six non-incapacitating episodes per year. The medical evidence of record shows that the Veteran was prescribed antibiotic treatment for an episode of sinusitis in 1999, and acute sinusitis was also diagnosed in 2007. That confirms the presence of active sinusitis symptomatology. The medical evidence does not show that the Veteran has even been prescribed bed rest for his sinusitis by a physician. As he is not a physician, the Veteran is not competent to make a determination that his sinusitis episodes required bed rest. Espiritu v. Derwinski, 2 Vet. App. 492 (1992); Grottveit v. Brown, 5 Vet. App. 91 (1993). Furthermore, the schedule requires that an incapacitating episode have bed rest prescribed by and treatment by a physician. Accordingly, the Veteran cannot be considered to experience incapacitating episodes of sinusitis for VA purposes, regardless of his own characterizations of the incapacitating effects of his sinusitis. The medical evidence of record shows that the Veteran has been consistently seen and treated for sinusitis symptoms between one and three times per year since 1999. The evidence of record does not show that, at any point during the period on appeal, the Veteran has received treatment for sinusitis more than six times in any one year. Accordingly, the Board finds that an initial rating in excess of 10 percent is not warranted, as the preponderance of the evidence of record is against a finding that the Veteran has ever experienced more than six non-incapacitating episodes of sinusitis in a single year. This issue has also been reviewed with consideration of whether staged ratings would be warranted. While there may have been occasional fluctuations of the Veteran's sinusitis symptoms, the evidence shows no distinct periods of time during which his symptoms have varied to such an extent that a rating in excess of 10 percent would be warranted under any diagnostic code. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.344 (2011); Fenderson v. West, 12 Vet. App. 119 (1999). The Board finds that the preponderance of the evidence is against the claim for increase and that claim is denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Nasal Bone Fracture With Deformity The medical evidence of record shows that the Veteran's nasal bone fracture with deformity is manifested by bilateral total nasal obstruction, tenderness, diminished sense of taste, diminished sense of smell, abnormal voice, nasal polyps, abnormal turbinates, and significant nasal deformity. Allergic or vasomotor rhinitis warrants a 30 percent evaluation if it is with polyps. 38 C.F.R. § 4.97, Diagnostic Code 6522 (2011). A 30 percent rating is the highest rating provided in the Schedule for allergic or vasomotor rhinitis. 38 C.F.R. § 4.71a, Diagnostic Code 6522 (2011). Accordingly, the Board finds that a higher schedular rating cannot be awarded for the Veteran's nasal disability under that diagnostic code. The Board has also considered rating the Veteran's nasal disabilities under all other diagnostic codes pertaining to the nose and throat. The Board notes that the evidence does not show that the Veteran's nasal disabilities impact his larynx or pharynx. Accordingly, the diagnostic codes corresponding to disabilities of those areas are not applicable. 38 C.F.R. § 4.97, Diagnostic Codes 6515, 6518, 6520. 6521 (2011). In addition, while the Veteran's nasal disability results in an abnormal voice with a nasal quality, the Board finds that this level of vocal distortion is not analogous to aphonia or chronic laryngitis, as the vocal distortion itself does not cause difficulty speaking or have independent physical manifestations equivalent with those contemplated by chronic laryngitis. Accordingly, the diagnostic codes corresponding to those disabilities are not for application. 38 C.F.R. § 4.97, Diagnostic Codes 6516, 6519 (2011). Furthermore, the medical evidence of record does not show that the Veteran has ever had rhinoscleroma or Wegener's granulomatosis. Accordingly, ratings in excess of 30 percent are not warranted under the corresponding diagnostic codes. 38 C.F.R. § 4.97, Diagnostic Codes 6523, 6524 (2011). With respect to the diagnostic codes corresponding to sinusitis, service connection is already in effect for sinusitis, and the Veteran's sinusitis symptomatology has already been independently rated. Accordingly, rating the Veteran's remaining nasal disabilities under Diagnostic Codes 6510, 6511, 6512, 6513, or 6514 would result in prohibited pyramiding. 38 C.F.R. §§ 4.14, 4.97, Diagnostic Codes 6510, 6511, 6512, 6513, 6514 (2011). Additionally, the Board notes that the Veteran experiences chronic sinus headaches. However, headaches are specifically contemplated by the rating assigned for the Veteran's sinusitis. 38 C.F.R. § 4.97, Diagnostic Code 6513 (2011). Therefore, providing a separate rating for the Veteran's headache symptomatology would also result in prohibited pyramiding. 38 C.F.R. § 4.14 (2011). The medical evidence of record shows that the Veteran experiences significantly reduced senses of smell and taste. However, the Veteran has repeatedly stated that he retains at least a minimal ability to smell and taste, and that any complete loss of those senses is only temporary. Accordingly, the Board finds that the preponderance of the evidence of record shows that the Veteran's nasal disability does not result in a complete loss of either smell or taste. Therefore, a separate compensable rating is not warranted for those related manifestations. 38 C.F.R. § 4.87a, Diagnostic Codes 6275, 6276 (2011). Finally, the medical evidence of record shows that the Veteran's nasal disability is manifested by a significant nasal deformity. That manifestation of the disability is not contemplated by the Veteran's currently assigned rating, nor is it contemplated by the rating assigned for his sinusitis. 38 C.F.R. § 4.97, Diagnostic Codes 6213, 6522 (2011). Loss of part of the nose warrants a 10 percent rating with loss of part of one ala, or other obvious disfigurement. A 30 percent rating is warranted for exposure of both nasal passages. 38 C.F.R. § 4.97, Diagnostic Code 6504 (2011). The medical evidence of record shows that the Veteran's nasal deformity is manifested by a significant depression and collapsed nasal structure. The Board finds that represents an obvious disfigurement because the evidence of record shows that it is obvious upon examination of the nose and that it is a disfigurement and that there is loss of the nasal cartilage. Accordingly, the Board finds that a separate 10 percent rating is warranted under 38 C.F.R. § 4.97, Diagnostic Code 6504 (2011). However, the Board finds that a 30 percent rating is not warranted under that diagnostic code, because the medical evidence of record shows that the Veteran's nasal passages are not exposed. 38 C.F.R. § 4.97, Diagnostic Code 6504 (2011). This claim has also been reviewed with consideration of whether staged ratings would be warranted. While there may have been occasional fluctuations of the Veteran's nasal disability symptoms, the evidence shows no distinct periods of time during which his symptoms have varied to such an extent that a rating in excess of 30 percent would be warranted under any diagnostic code. 38 U.S.C.A. § 5110 (West 2002); Hart v. Mansfield, 21 Vet. App. 505 (2007). Accordingly, the Board finds that the evidence supports the assignment of a separate 10 percent rating for nasal deformity. However, the preponderance of the evidence is against the assignment of any higher or other separate rating. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Final Considerations Generally, rating a disability using either the corresponding or analogous diagnostic codes contained in the Schedule is sufficient. 38 C.F.R. §§ 4.20, 4.27 (2011). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2011). The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular ratings for that service-connected disability are inadequate. Thun v. Peake, 22 Vet. App. 111 (2008); Fisher v. Principi, 4 Vet. App. 57 (1993). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). If the criteria under the Schedule reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Schedule, and the assigned schedular rating is adequate, and no referral is required. When service-connected disability affects employment in ways not contemplated by the rating schedule, § 3.321(b)(1) is applicable. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996). The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render his disabilities rating for sinusitis, nasal deformity, or nasal disability inadequate. The Veteran's sinusitis and nasal disability were rated under 38 C.F.R. § 4.97, Diagnostic Codes 6504, 6513, and 6522 (2011), the criteria of which are found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. The Veteran's sinusitis is manifested by no more than six non-incapacitating episodes per year, while his nasal bone fracture with deformity is manifested by bilateral total nasal obstruction, tenderness, diminished sense of taste, diminished sense of smell, abnormal voice, nasal polyps, abnormal turbinates, and significant nasal deformity. When comparing this disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are adequately contemplated by the disabilities rating assigned for his sinusitis, nasal deformity, and nasal disability. Ratings in excess of the currently assigned ratings are provided for certain manifestations of nasal disabilities, but the medical evidence shows that those manifestations are not present in this case. The criteria for a the currently assigned ratings for the Veteran's sinusitis and nasal disability more than reasonably describe the Veteran's disability level and symptomatology and, therefore, the Board finds that the currently assigned schedular ratings are adequate and no referral is required. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996); 38 C.F.R. § 4.97, Diagnostic Codes 6504, 6513, and 6522 (2011). Finally, while there is evidence of record that the Veteran's nasal disabilities may impact his employment, that issue is for consideration in conjunction with the TDIU claim being remanded below. In reaching this decision, the Board finds that the preponderance of the evidence of record shows that the Veteran's sinusitis and nasal disability do not meet the criteria for ratings in excess of those assigned herein. Therefore, the claim for increased ratings beyond those assigned herein is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Massey v. Brown, 7 Vet. App. 204 (1994). ORDER An initial rating in excess of 10 percent for sinusitis with diminished sense of smell and taste is denied. A rating in excess of 30 percent for status post nasal bone fracture with deformity, total bilateral nasal obstruction and profound vasomotor reaction with bilateral polyps, is denied. A separate rating of 10 percent, but not higher, for nasal deformity under Diagnostic Code 6504 is granted. REMAND The Veteran claims entitlement to TDIU. Entitlement to TDIU is warranted if the Veteran is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a) (2011). In such an instance, if there is only one service-connected disability, it must be rated at 60 percent or more; if there are two or more service-connected disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a) (2011). The Veteran's combined disability rating is 40 percent. 38 C.F.R. § 4.25 (2011). While that combined rating does not take into account the rating to be assigned for the Veteran's nasal deformity, which has been granted herein, the highest rating possible under the applicable diagnostic code is 30 percent. 38 C.F.R. § 4.97, Diagnostic Code 6504 (2011). Accordingly, even if the highest rating were assigned for the Veteran's nasal deformity, the percentage criteria of 38 C.F.R. § 4.16(a) would still not be met. However, if a Veteran does not meet the applicable percentage standards set forth in 38 C.F.R. § 4.16(a), a total rating due to unemployability rating may be considered where the Veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disability. 38 C.F.R. § 4.16(b) (2011); Fanning v. Brown, 4 Vet. App. 225 (1993). In this case, the Veteran was provided with a VA medical examination in September 2010, in part to determine whether his service-connected disabilities prevented him from securing or following a substantially gainful occupation. The examiner opined that the Veteran was not employable due to the difficulty of doing any kind of exerted job while continuously mouth breathing. However, the September 2010 examination report did not include any kind of work and educational history or address whether any sedentary employment was possible. The Board notes that there is no evidence of record which provides the Veteran's complete work and educational history. The most recent evidence of record which provides any kind of information regarding the Veteran's employment status is an April 2006 statement from the Veteran in which he stated that he missed days from work because he was sick and could not perform his job as he was usually able. That statement is evidence that the Veteran was employed in April 2006, and there is no evidence of record which states that the Veteran has become unemployed since that time. In the absence of any information regarding the Veteran's work and educational history, or his current employment status, the Board finds that the September 2010 VA examination does not provide a competent opinion as to whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities alone. If VA provides the Veteran with an examination, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Therefore, the TDIU claim must be remanded for a new examination as the September 2010 VA medical examination was inadequate. 38 C.F.R. §§ 3.312(c)(3); 3.159(c)(4) (2011). With regard to the claim of entitlement to an effective date earlier than March 9, 2004, for the assignment of a 30 percent rating for status post nasal bone fracture with deformity, total bilateral nasal obstruction, and profound vasomotor reaction with bilateral polyps, the 30 percent rating was granted by a November 2004 rating decision. In September 2005, the Veteran's representative submitted a notice of disagreement with respect to the November 2004 rating decision, and specifically appealed both the rating and the effective date assigned. Accordingly, the Board finds that the September 2005 statement from the Veteran's representative constitutes a timely notice of disagreement with the effective date assigned for the 30 percent rating for status post nasal bone fracture with deformity, total bilateral nasal obstruction and profound vasomotor reaction with bilateral polyps in November 2004. 38 C.F.R. § 20.201 (2011). The filing of a notice of disagreement initiates the appeal process. Godfrey v. Brown, 7 Vet. App. 398 (1995). The rating assigned was subsequently addressed by the RO in a statement of the case and the appeal was perfected to the Board in August 2011. However, the RO has not provided the Veteran with a statement of the case with respect to the earlier effective date claim. 38 C.F.R. § 19.26 (2011). Where a notice of disagreement has been filed with regard to an issue, and a statement of the case has not been issued, the appropriate Board action is to remand the issue for issuance of a statement of the case. Manlincon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following actions: 1. Issue a statement of the case on the issue of entitlement to an effective date earlier than March 9, 2004, for the assignment of a 30 percent rating for status post nasal bone fracture with deformity, total bilateral nasal obstruction, and profound vasomotor reaction with bilateral polyps. If the Veteran perfects an appeal, return the case to the Board. 2. Schedule the Veteran for a VA examination to determine whether he is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities alone. The examiner must review the claims file and note that review in the report. The examiner must elicit from the Veteran and record for clinical purposes a full work and educational history. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's service-connected disabilities alone preclude him from securing and following substantially gainful occupational experience. The examiner is instructed to provide the opinion without respect to the impact of the Veteran's age on his employability. If the Veteran is found to be employable, the examiner should explain what types of employment could be performed. A complete rationale for all opinions must be provided. 3. Then, readjudicate the TDIU claim. If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow the applicable time for response. Then, return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or the United States Court of Appeals for Veterans Claims for development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2011). ______________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs