Citation Nr: 1310089 Decision Date: 03/25/13 Archive Date: 04/02/13 DOCKET NO. 08-32 101 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for vocal cord dysfunction. ATTORNEY FOR THE BOARD J. Connolly, Counsel INTRODUCTION The Veteran served on active duty from August 2003 to June 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio, in which the RO denied service connection for asthma and vocal cord dysfunction. In May 2010, the Board remanded the claims for service connection for asthma and vocal cord dysfunction to the RO via the Appeals Management Center (AMC) in Washington, DC, for further development. In an October 2011 rating decision, the AMC granted service connection for asthma, representing a full grant of the benefit sought with respect to that claim which had been appealed to the Board. The AMC also granted a 10 percent rating based on multiple, noncompensable service-connected disabilities. The AMC continued to deny the claim for service connection for vocal cord dysfunction (as reflected in an October 2011 supplemental statement of the case (SSOC)), and returned this matter to the Board for further appellate consideration. In August 2012, the Board again remanded this case to the AMC. The issue of service connection for vocal cord dysfunction is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. REMAND Unfortunately, a remand is required in this case. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claim so that the Veteran is afforded every possible consideration. The Veteran asserts that he has vocal cord dysfunction related to service. His service treatment records include findings of a lazy vocal cord. In the Board's recent remand, it was noted that the claim was previously remanded to afford the Veteran a VA examination to evaluate his claimed vocal cord dysfunction. The VA examiner was instructed to provide an explicit response to the following questions: (1) Is it at least as likely as not that the Veteran currently has vocal cord dysfunction; and (2) If the Veteran currently has vocal cord dysfunction, is it as likely as not that it was caused by his military service. Thereafter, following the prior remand, the Veteran was afforded VA pulmonary and ear, nose, and throat (ENT) examinations in July 2010. The pulmonary examiner noted that the Veteran's claims file documented his history of diagnoses of moderate persistent asthma and vocal cord dysfunction, for which he was separated from the Marine Corps. The pulmonary examiner did not address current vocal cord dysfunction; rather, her diagnosis following examination was asthma, and the reader was referred to the VA ENT examination for other diagnoses. The Veteran then underwent a VA ENT examination. The ENT examiner noted that the Veteran's main trouble was asthma. He indicated that, since the Veteran was being seen by pulmonary medicine after leaving his VA examination, he would let pulmonary medicine make the determination and description of his problems. The Veteran described no difficulty with phonation, although he did have occasional hoarseness. The Veteran reported that he had been diagnosed with vocal cord dysfunction at Camp Lejeune, which caused pausing in his breathing. On examination, the oral cavity and hypopharynx were unremarkable. Both vocal cords moved. The left vocal cord did not move or abduct as well as the right, but the vocal cords did meet in the midline. The Veteran did not have any problem with voice usage due to his vocal cords. The examiner commented that he would describe the left vocal cord as lazy. He continued, stating, "[p]ast that, stroboscopic evaluation would probably be indicated if this is not necessary." The impression following examination was that the Veteran may have an allergic rhinitis. The examiner added that there was no evidence of soft palate injury, and the Veteran had not had any laryngeal surgery. Thereafter, the Veteran was afforded a VA Nose, Sinus, Larynx, and Pharynx examination in September 2011. Examination of the right nasal passageway was patent. There was no purulent drainage, crustiness, or polyps. The septum was slightly deviated to the left and there was slight swelling of the turbinates. Clear to white drainage was noted. There was no tenderness over the right frontal or right maxillary sinus and the left nasal passageway was patent. There was slight swelling of the turbinates without any crustiness or purulent drainage. There was also no tenderness over the left frontal or left maxillary sinus. The oropharynx had small amounts of postnasal drip noted. X-rays of sinuses were taken and reviewed and were normal. The diagnosis was allergic rhinitis/sinusitis. The examiner opined that it was at least as likely as not that the Veteran's allergic rhinitis is related to the military. However, no opinion was provided regarding a vocal cord disability. In a September 2011 rating decision, service connection for allergic rhinitis was granted. As noted, an October 2011 rating decision also granted service connection for asthma. The Board then remanded this case in August 2012 because it was unclear whether the prior finding of a lazy left vocal cord might constitute vocal cord dysfunction since the VA examinations were unclear on that point. It was noted that while the Veteran had been scheduled for a VA examination, he did not report for that examination. It was also noted that several attempts, by phone and mail, were made to contact the Veteran with regard to the VA examination, to no avail. See Failure to Prosecute Memorandum dated April 2012. The Board also indicated that the treatment records from the Cleveland VAMC had not been associated with either the paper file or the Virtual VA e-folder. In light of the foregoing, the Board remanded this case for the missing records and to make another attempt to afford the Veteran a VA ENT examination to determine the etiology of any vocal cord disorder, to include vocal cord dysfunction. Thereafter, the AMC/RO attempted to schedule the Veteran for a VA examination, but he did not report. It is apparent that VA may not have his current address and contact information. The AMC/RO did obtain the missing VA medical records. These records, contained in the Virtual VA e-folder, included an April 20, 2012 evaluation conducted at the Cleveland VA Medical Center. This tends to show that the Cleveland VA Medical Center might have the Veteran's current address and contact information. Likewise, as the Veteran is being paid benefits by VA, the financial institution in receipt of those benefits should also have that information. Although it is the Veteran's responsibility to notify VA of changes in address, it appears that the Cleveland VA Medical Center was provided that information. Turing to the April 20, 2012 report, this record reflects that the Veteran underwent an examination. At that time, the Veteran felt that his voice had been "cracking" and had been hoarse more frequently the past year or two. He also related that he had frequent nasal sniffing (which was observed during this examination) and frequent throat clearing to where he spit up yellow mucous. Also, the Veteran reported having reflux symptoms. A Reflux Symptom Index (Belafsky, Postma, Amin, Koufman, 2002) was administered to obtain subjective information regarding the Veteran's perception of symptoms of LPR (laryngopharyngeal reflux). It was noted that the lower the score, the less likely the symptoms of LPR. The Veteran had a score of 24 (out of 45) on RSI which was considered abnormal. He endorsed hoarseness, throat clearing, postnasal drip, coughing after lying down, troublesome cough, a sensation of material sticking his throat, heartburn/chest pain/indigestion, and breathing difficulties. The Veteran was not currently taking medication for reflux. Oral structures were observed to be without abnormalities. During conversational speech and reading tasks, the Veteran's voice scored the following: his pitch was mildly high, his rate was normal, his loudness was normal, his range was normal, his quality was normal, and his nasal oral resonance was mildly hypernasal. A videostroboscopy was performed which revealed no significant abnormalities noted during this evaluation. His R and L TVC movement was observed to be symmetrical. He had a small posterior glottic chink during phonation at conversational level. The glottic chink was not present when he was asked to voice loudly. There was adequate mucosal wave movement and normal horizontal amplitude noted. There was no significant pooling of secretions observed. There was a questionable slightly red appearance of arytenoids and false vocal cords during this study. The examiner opined that the Veteran would benefit from an evaluation for gastroesophageal reflux disease (GERD) given his score on RSI. A speech pathologist signed the report. In sum, the newly associated evidence suggests that GERD may be the etiology of the Veteran's voice/vocal cord complaints or hoarseness and voice changes. The Board recognizes that repeated attempts have been made to examine this Veteran again, although he did report on his own for the April 2012 outpatient speech pathology evaluation. The Board finds that given the findings of the VA speech pathologist, the Veteran should be evaluated for GERD. If the AMC/RO remains unable to schedule the Veteran for an evaluation, a medical opinion should be obtained, nonetheless, based on the available evidence of record, as to whether the Veteran has GERD which is related to service and whether it is manifest by vocal cord dysfunction. Since the case is being remanded, any medical records post-dating April 20, 2012 should be obtained from the Cleveland VA Medical Center. Accordingly, the case is REMANDED for the following action: 1. Contact the Cleveland VA Medical Center as well as the financial institution which processes the Veteran's VA benefits and verify his correct address and contact information. 2. Obtain and associate with the record copies of all clinical records after April 20, 2012, from the Cleveland VA Medical Center. 3. Schedule the Veteran for a GERD examination to determine the nature and etiology of any current disability. Any indicated tests should be accomplished. The examiner should review the record prior to the examination. The examiner is requested to provide the following opinion. In addition, even if the Veteran fails to report for the scheduled examination, the following opinion should be provided by a qualified examiner. The examiner should provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that any current GERD had its clinical onset during service or is related to any in-service disease, event, or injury. If the answer to this inquiry is affirmative, the examiner should also opine as to whether the GERD is manifested by vocal dysfunction, such as hoarseness and vocal changes. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. 3. The AMC should review the medical opinion obtained above to ensure that the remand directives have been accomplished. If all questions posed are not answered or sufficiently answered, AMC should return the case to the examiner for completion of the inquiry. 4. The AMC should then readjudicate the claim on appeal in light of all of the evidence of record. If the issue remains denied, the Veteran should be provided with a supplemental statement of the case as to the issue on appeal, and afforded a reasonable period of time within which to respond thereto. The appellant 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). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2002 & Supp. 2012). _________________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002 & Supp. 2012), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).