Citation Nr: 1317265 Decision Date: 05/28/13 Archive Date: 06/06/13 DOCKET NO. 10-22 069 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for residuals of parvovirus B19 (fifth's disease) infection, to include arthropathy, tendonitis, and bursitis of the bilateral shoulders, hands, wrists, hips, knees, and ankles, neck, and lower back. 2. Entitlement to service connection for Eustachian tube dysfunction. 3. Entitlement to service connection for failed root canal with #14 molar extraction for VA compensation purposes. 4. Entitlement to an initial rating higher than 50 percent for migraine headaches. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Sarah Richmond, Counsel INTRODUCTION The Veteran had active military service from February 1990 to September 1997; he also reportedly had four 45-day periods of prior active duty service. This matter comes to the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. In October 2008, the RO, in pertinent part, granted service connection for migraine headaches assigning a 30 percent rating, effective February 10, 2008; and denied service connection for polyarthritis and bursitis of the bilateral shoulders, bilateral hands and wrists, bilateral hips, bilateral knees, bilateral ankles, neck, and lower back. The RO also denied service connection for Eustachian tube dysfunction and failed root canal with #14 molar extraction. In April 2010 the RO assigned a higher initial rating of 50 percent for migraine headaches, effective February 10, 2008. The Veteran testified before the undersigned Veterans Law Judge at a Board central office hearing in May 2011. The service connection claims for polyarthritis and bursitis of the multiple joints have been modified as reflected on the first page of this decision based on statements and testimony from the Veteran clarifying the disability that he is actually claiming. Rather than arthritis of the multiple joints, he is essentially claiming residuals of parvovirus B19 infection (fifth's disease) acquired in service that is now manifested primarily by joint pain, tendonitis, and bursitis of the multiple joints. The issue of entitlement to service connection for a dental disability for treatment purposes only has been raised by the record, but this issue does not appear to have been adjudicated. Therefore, the Board does not have jurisdiction over it, and it is referred to the RO for appropriate action. Specifically, the RO should refer the claim for dental treatment to the appropriate VA Medical Center. The issues of entitlement to service connection for Eustachian tube dysfunction, and residuals of parvovirus B19 (fifth's disease) to include arthropathy, tendonitis, and bursitis of the bilateral shoulders, hands, wrists, hips, knees, ankles, neck, and lower back, as well as the claim for an initial rating higher than 50 percent for migraine headaches are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran underwent a root canal to molar #14 in service, which ultimately resulted in extraction of the tooth. 2. The Veteran's loss of molar #14 is not the result of loss of substance of the body of the maxilla or mandible, or otherwise the result of loss of the ramus, loss of the condyloid or coronoid processes, or loss of the hard palate; also the tooth was replaced by a suitable prosthesis that did not inhibit the masticatory process. 3. Under the laws administered by VA, replaceable missing teeth are not a disability for which VA disability compensation is payable. CONCLUSION OF LAW The criteria for service connection for dental trauma due to failed root canal resulting in extraction of molar #14, for VA compensation purposes, have not been met. 38 U.S.C.A. §§ 1110, 1131, 1712 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.381, 4.150, 17.161 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 & 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable AOJ decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). In the current appeal, a pre-decisional letter dated in February 2008 complied with VA's duty to notify the Veteran of what he needed to substantiate his claim for service connection. Specifically, this letter apprised the Veteran of what the evidence needed to show to establish entitlement to the benefit sought, what additional evidence and/or information was needed from him, what evidence VA was responsible for getting, and what information VA would assist in obtaining on his behalf. Additionally, the letter notified the Veteran of the criteria for assigning a disability rating and an effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Therefore, adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board and complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). Additionally, VA has a duty to assist a veteran in the development of his/her claim. This duty includes assisting him/her in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Here, the Veteran's service treatment records (STRs) have been obtained and associated with the claims folder, and the RO also secured a VA dental examination in furtherance of the Veteran's claim. The VA examination obtained is sufficient, as it considered all of the pertinent evidence of record, including the statements of the Veteran. VA has no duty to inform or assist that was unmet. The Veteran has not identified any additional pertinent medical records, which have not been obtained and associated with the claims folder. The Veteran has been afforded a hearing before the undersigned Veterans Law Judge (VLJ) in which he presented oral argument in support of his service connection claim for diabetes mellitus. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2010) requires that the VLJ or DRO who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the VLJ noted the elements that were lacking to substantiate the claim and specifically sought to clarify the Veteran's contentions regarding his dental claim as well as his periods of active duty service. The Veteran also volunteered his treatment history and symptoms since service. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). The duty to assist has therefore been satisfied and there is no reasonable possibility that any further assistance to the appellant by VA would be capable of substantiating his claim. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the appellant in adjudicating this appeal. II. Analysis Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The Veteran's DD-214 reflects that he had active military service in the Air Force from February 1990 to September 1997 with no prior active service. However, the Veteran testified that prior to his service in the Air Force he was in the health professional scholarship program for medical school and performed active duty for 45-day periods every summer for four years of medical school. He contends that his dental issue began during one of those periods in 1983. Although the Veteran's personnel records are not in the file, the service treatment records show that on August 16, 1983 the Veteran underwent examination for purposes of extended active duty. The dental treatment in question is documented on a dental record dated August 19, 1983. Therefore, for purposes of this decision, the Board will resolve all doubt that the Veteran was on active duty service during his initial dental treatment at issue in August 1983. The issue presented for appellate consideration is service connection for compensation purposes for failed root canal with #14 molar extraction. Disability compensation and VA outpatient dental treatment may be provided for certain, specified types of service-connected dental disorders. For other types of service-connected dental disorders, the claimant may receive treatment only and not compensation. 38 U.S.C.A. § 1712; 38 C.F.R. §§ 3.381, 4.150, 17.161. On review of the facts of this case, the issue of entitlement to dental treatment has been raised and has thus been referred to the RO, as noted in the introduction. In May 2011 the Veteran testified that he was experiencing cold sensitivity on the top left molar from a filling he had as a child, while he was on medical rotation at Wolford Hall. His dentist decided that they should do a root canal. However, during the procedure the dentist fractured and drilled through the tooth root and hit the gingival artery. Later in 1994 while on active duty at Scott Air Force Base, an oral surgeon extracted the tooth as it had become infected and the abscess had ascended the maxillary bone and damaged the floor of the maxillary sinus. He did not get surgery at that time, as he was too busy in his duties as a cardiologist in the Air Force. About six years after service, in 2006, he was eating a Doritos chip and furthered injured his gum. He had a sinus lift with cativary bone implant and a false tooth put in. He complained that he still would get bad erosive mouth sores; also the cativary graft was stable but resorbing, as well as the bone that his molars surrounding it were hooked to. Service treatment records from Lackland Air Force Base note that on August 19, 1983, which the Board will presume was during one of his 45-day periods of active duty, the Veteran had complaints of periodic achy and tender tooth with a history of pulpotomy about age 10. The diagnosis was mild apical periodontitis. It was noted that the "MB and P" canals were located and that a pulpectomy was performed with inadvertent disto-buccal furcal perforation. The cavity was sealed with a cotton pellet. By August 23, 1983 his symptoms had much improved and cavity perforation repair was intact. During his next period of active duty, on June 2, 1994, the Veteran presented with facial swelling at #14 which had been present for at least a month. The area had drained and reswollen. It was noted that #14 had a history of endodontic root canal 10 years prior. At that time there was perforation to the distal root. No fill material was present in the apical 1/2 of the distal root. It was noted that the dentist who had put a cast restoration on the tooth had told the Veteran he had fractured the tooth. Examination revealed a swelling in the facial furcal of #14 but the dentist was unable to probe any significant periodontic pocket. The Veteran was referred for treatment. On June 14, 1994, x-rays revealed loss of furcation bone and apical radiolucencys. It was felt that prognosis was helpless and that the #14 cracked tooth should be extracted. The extraction was performed June 16, 1994. After service a private April 2001 dental record notes that the Veteran was referred for possible implant placement. The Veteran related that he had had a previous tooth extracted four to five years ago and had been recommended for replacement of this tooth with an implant. He had had no complaints with chewing in this area. Physical examination showed no facial edema or masses. His dentition was intact except he was missing tooth #14. This area appeared to have been somewhat of a traumatic extraction as the buccal alveolus was severely atrophic relative to the adjacent teeth. No soft tissue lesions or masses were otherwise noted. There appeared to be lack of attached tissue on the buccal aspect. X-rays revealed approximately 1mm of bone in the area of tooth #14 as the sinus was markedly pneumatized into that area. There was no osseous pathology otherwise noted. The assessment was atrophic maxillary alveolar ridge with pneumatized sinus in the area of tooth #14. The tentative treatment plan included bone grafting of the autogenous bone with the use of platelet-rich plasma in the area of tooth #14 and secondarily placing an implant. The next treatment record is dated July 2005. The Veteran returned for re-evaluation and re-consultation regarding implant reconstruction in the maxillary left. It was noted that he had been recommended for implant reconstruction in this area. He had noted some recession in this area and felt that this area required grafting. It was noted that he had been evaluated back in 2001 for this and that it had been explained to him at that time that he needed a sinus lift. Physical examination showed no facial edema or masses. He was missing tooth #14 and had multiple edentulous areas. This area was extremely atrophic on the buccal aspect with very minimal attached gingival on the alveolar crest. There were no soft tissue lesions or masses otherwise noted. There appeared to be adequate interdental spacing between teeth #13 and 15. The alveolus was very thin in this area. He had some mild recession on the adjacent teeth #13 and 15. X-rays revealed extreme atrophy of the alveolus and severe pneumatization of the maxillary left sinus in the area of tooth #14. There was 1mm or less of residual alveolar ridge in this area. No osseous pathology was otherwise noted. The assessment was severe atrophic maxillary ridge with severe pneumatized sinus region of edentulous are tooth #14. The plan was to do an open sinus window bone grafting in the area of tooth #14. Secondarily an implant would be placed. In January 2006, the Veteran returned for grafting of his left maxillary sinus with a sinus lift. Later treatment records in January and April 2006 note major aphthous ulcers. In July 2006 the Veteran was without complaint; the area was well-healed. The Veteran returned for an implant in the area of tooth #14 in September 2006. A later September 2006 treatment record notes the Veteran was without complaint with no evidence of infection or breakdown. In March 2007, the Veteran returned for reverse torquing of the implant in the area of tooth #14. There was no discomfort experienced by the Veteran and no movement. The x-rays showed good osseous healing; the bone was not as consolidated as densely as the doctor would prefer but it was healed enough for the implant to be considered integrated. A separate March 2007 treatment record notes the Veteran was still dealing with aphthous ulcers and had found that this immune system had become dependent on steroid rinses for ulcers. In April 2008 the Veteran underwent a subepithelial connective tissue graft at facial #14. His prognosis was good. In the report of June 2008 VA dental examination, the examiner noted that the Veteran had alveolar bone resorption of the #14 area. The area was continuing to be irritating to the Veteran due to food impactions. The adjacent teeth also had been affected due to bone loss. The diagnosis was alveolar bone loss after extraction of tooth #14. The bone loss was present from interproximal of #13 and #15. Tooth #13 also was sensitive to percussion. It was noted that tooth #14 had needed to be extracted due to failed endodontic treatment while in service in 1983 and that after the extraction of tooth #14, the alveolar bone had become resorbed. The examiner noted that there was no loss of bone of the maxilla, malunion or nonunion of the maxilla, loss of bone of the mandible, nonunion or malunion of the mandible, limitation of motion at the temporomandibular articulation, loss of bone of the hard palate, evidence of osteoradionecrosis, or evidence of osteomyelitis. There also was no tooth loss due to loss of substance of body of maxillary or mandible. In light of the evidence, above, the Board notes that disability compensation may be provided for certain specified types of service-connected dental disorders (Class I). See 38 C.F.R. § 17.161(a). The dental disabilities which may be awarded VA compensation are set forth under 38 C.F.R. § 4.150. These disabilities include chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible, loss of the mandible, nonunion or malunion of the mandible, limited temporomandibular motion, loss of the ramus, loss of the condyloid or coronoid processes, loss of the hard palate, loss of teeth due to the loss of substance of the body of the maxilla or mandible and where the lost masticatory surface cannot be restored by suitable prosthesis, when the bone loss is a result of trauma or disease but not the result of periodontal disease. 38 C.F.R. § 4.150, Diagnostic Codes 9900-9916. There is no time limitation for making application for treatment and no restriction as to the number of repeat episodes of treatment. In the present case, tooth #14 was extracted due to in-service trauma in August 1983 to the tooth when the dentist inadvertently perforated the furcation and reportedly cracked the tooth. Eventually the tooth had to be extracted in June 1994 after x-rays revealed loss of furcation bone and apical radiolucencys. The Veteran (who is a cardiologist) testified that the tooth had become infected and that the abscess had ascended the maxillary bone and damaged the floor of the maxillary sinus. After service the Veteran underwent grafting of his left maxillary sinus with a sinus lift in January 2006 and had an implant in the area of tooth #14 in September 2006. A later September 2006 treatment record notes the Veteran was without complaint with no evidence of infection or breakdown. In March 2007, the Veteran returned for reverse torquing of the implant in the area of tooth #14. X-rays showed good osseous healing; the bone was not as consolidated as densely as the doctor would prefer but it was healed enough for the implant to be considered integrated. In April 2008 the Veteran underwent a subepithelial connective tissue graft at facial #14. His prognosis was good. There is no competent evidence that the Veteran has lost a tooth as a result of loss of substance of body of maxilla or mandible, from loss of the ramus, from loss of the condyloid or coronoid processes, or from loss of the hard palate. See 38 C.F.R. § 4.150. Although tooth #14 was extracted after loss of the furcation bone it was not indicated that the tooth was extracted due to loss of the substance of the body of the maxilla at that time. While the Veteran testified that the infection in the #14 molar had ascended the maxillary bone he did not contend that there was loss of substance of the maxillary bone. The June 2008 VA examination report also confirmed that there was no loss of bone of the maxilla, or tooth loss due to loss of substance of body of maxilla or mandible. In addition, even if the argument was made that the Veteran's assessment of an abscess ascending the maxillary bone was akin to loss of substance of the bone, the Veteran would still not be entitled to compensation under 38 C.F.R. § 4.150, as the tooth was replaced by a suitable prosthesis that did not inhibit the masticatory process (although later the alveolar bone was resorbed, which was irritating on food impaction). Therefore, the Veteran is not eligible for compensation associated with the loss of tooth #14, as this is not a disability for which compensation may be paid. ORDER Entitlement to service connection for failed root canal with #14 molar extraction is denied for VA compensation purposes. REMAND The Veteran testified that he is seeking compensation for residuals of a parvovirus infection he incurred in service. He states that the infection happened in 1993 and that he has continued to have arthropathy in his multiple joints, including his shoulders, hands, wrists, hips, knees, ankles, neck, and lower back since that time. He said that he wanted an infectious disease specialist or rheumatologist to evaluate him during a flare-up and that he saw a rheumatologist at the VAMC every three months. The service treatment records show that in June 1993 the Veteran was assessed as having adult variant parvovirus B19 infection. He had complaints of moderate to moderately severe arthralgias affecting the axial skeleton, as well as a rash that was resolving. In August 1996 the Veteran complained of left lateral hip pain and was diagnosed with trochanteric bursitis. On his report of medical history at separation from service in July 1997 the Veteran complained of swollen or painful joints, including back pain, neck stiffness, and ankle tendonitis, as well as left wrist pain and numbness. It was noted that he had ankle tendonitis diagnosed in 1969 and that he had self-diagnosed himself with arthritis in the back due to injury in 1975. It was noted that the Veteran had been diagnosed with fifths disease in 1993, which was complicated by morning stiffness. He was evaluated by the infectious disease clinic at Scott Air Force Base; no treatment was required for viral joint disease. The Veteran also had self-diagnosed carpal tunnel syndrome in June 1997; no treatment sought; he had full range of motion. The July 1997 separation examination report showed a tender left acromioclavicular joint, left wrist, and second metacarpal joint. He was diagnosed with arthralgias of the multiple joints. After service, a June 2008 VA joints examination report shows the Veteran reported experiencing symptoms of malaise, macular rash and severe arthralgia while stationed at Scott Air Force Base in 1993. He was diagnosed with parvovirus B19 infection. He reported that the majority of his symptoms improved in a couple of weeks but that he continued to have recurring arthropathy and joint stiffness. He reported intermittent pain and swelling to the bilateral knees, ankles, wrists, and proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints. He also stated that he had intermittent pain and stiffness in his right shoulder and bilateral hips. On physical examination there was no swelling or erythema noted in the bilateral joints of the hands. There was slight tenderness at the DIP and PIP joints of the hands. There was normal active and passive range of motion of the bilateral hands, with no limitation of motion due to pain, fatigue, or weakness. Limited x-ray examination of the shoulders and ankles was normal. The diagnosis was arthropathy status post parvovirus. In the examiner's opinion it was less likely than not that the Veteran's arthropathy was secondary to his diagnosis of parvovirus B19 infection. The examiner then noted that according to the Veteran's service treatment records he was diagnosed with parvovirus B19 infection in 1993. The examiner indicated that parvovirus B19 can present as an acute arthritis and that although joint symptoms usually resolved in three weeks, a minority of patients developed persistent or recurring arthropathy. The Board notes that the Veteran's representative commented at the Board hearing that the June 2008 VA examiner appeared to contradict himself by stating that the arthropathy was both at least as likely as not and not at least as likely as not related to the parvovirus infection in service. It appears that the Veteran's representative is referring to the section of the report wherein the medical question was restated. Although there is no question mark at the end of the sentence and there is an apparent typographical error, it appears that this refers to the question asked of the examiner - it is at least as likely as not that the Veteran's chronic arthropathy is secondary to the Veteran's diagnosis of parvovirus B19 infection - rather than representing the examiner's opinion on the matter. The Board makes this deduction, as the statement appears after "Restatement of the Requested Opinion." Then later in the report after "Opinion" the examiner indicates that in his opinion it is less than likely the Veteran's chronic arthropathy is secondary to parvovirus B19 infection. Nonetheless, the examiner's opinion is insufficient as a rationale was not provided for the opinion. The examiner acknowledged that parvovirus can present as an acute arthritis and that in a minority of patients it can persist as recurring arthropathy, but then did not explain why it was the examiner's opinion that in the Veteran's case, his arthropathy was not related to his parvovirus infection in service. As a rationale was not provided for this opinion, the Board cannot rely on it in making a determination in this case. A medical opinion must support its conclusions with analysis. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). "Neither a VA medical examination report nor a private medical opinion is entitled to any weight in a service-connection or rating context if it contains only data and conclusions [without reasoning or rationale]." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). It is also not clear which joints the Veteran is actually complaining about. Although he filed claims for arthropathy of the lower back and neck, he did not complain about pain in these areas on examination in June 2008. It is also significant that the Veteran's separation report of medical history in July 1997 mentions that the Veteran had self-diagnosed arthritis due to an old lower back injury in 1975 and had a diagnosis of ankle tendonitis in 1969 (prior to his military service). The Veteran has stated that he has experienced joint pain since his parvovirus infection. A lay person is capable of observing continued symptoms such as joint pain. As the Veteran is a cardiologist, his opinion is entitled to even greater weight than that of a lay opinion. Nonetheless, as a cardiologist, he is not necessarily qualified to make an assessment of present disability related to his parvovirus infection, as he does not have a specialty in infectious diseases. Clinical evaluation of the Veteran's multiple joints also has been normal, other than the Veteran's complaints of pain. Pain alone, without a diagnosed or identifiable underlying condition does not constitute a disability for which service connection may be granted. Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999), appeal dismissed in part, and vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). Given the inadequacy of the June 2008 VA medical opinion, the Veteran's reports as a medical professional and opinion that his present arthropathy is related to his in-service diagnosis of parvovirus infection, and his request for an examination during a flare-up with an infectious disease specialist or rheumatologist, the Board finds that another medical opinion is warranted in this matter to determine what impairment the Veteran presently has as a result of his parvovirus B19 infection in service, and which joints are involved. If possible, the examination should take place during an active stage. Ardison v. Brown, 6 Vet. App. 405, 408 (1994). As the Veteran has indicated ongoing treatment with a rheumatologist at the VAMC these records also should be obtained on remand, as well. Regarding the Veteran's service connection claim for Eustachian tube dysfunction, the Veteran testified that his ears started feeling plugged up in service in 1994 and he was diagnosed with Eustachian tube dysfunction. He further testified that his ears had continued to feel plugged up after service, that he would treat his symptoms with antihistamines and drying agents, and that he would get intermittent ear infections that were treated with antibiotics. His service treatment records show the Veteran was assessed as having Eustachian tube dysfunction of the right ear in July 1993. By May 1994 the Eustachian tube dysfunction had resolved. At separation from service in July 1997, clinical evaluation of the ear drums showed scarring in both ears. On his July 1997 report of medical history the Veteran complained of ear, nose, or throat trouble. It was noted that the Veteran had been diagnosed with Eustachian tube dysfunction in 1992, mostly on the left. Currently he had an H2 profile and had hearing loss in both ears. His last infection was June 1997. He also had been diagnosed with myringitis bulosa in 1983 and was treated at Enburough Scotland, manifested by hemorrhaging of the left tympanic membrane. He had been hospitalized for two days and treated with antibiotics. After service in June 2008, the Veteran underwent an ear, nose, and throat (ENT) examination. The Veteran complained of intermittent fullness in the ears. The examiner noted it was impossible for him to comment on the Veteran's Eustachian tube dysfunction as he did not have a tympanogram to view in order to assess middle ear function and hence Eustachian tube function or dysfunction. His tympanic membranes appeared grossly within normal limits and the examiner saw no obvious evidence of tympanic membrane scarring. The examiner also determined that the Veteran's hearing loss might be related to his noise exposure in service. The Board notes, however, that a June 2008 audiological evaluation demonstrated no hearing loss for VA purposes. The audio examination noted the Veteran's complaints of Eustachian tube dysfunction with onset in the military with ongoing present complaints every six months with complaints of pressure in the ears and hearing loss. Given that the examiner in June 2008 did not evaluate the middle ear function, as he did not have the proper equipment, the examination is insufficient for rating purposes, as there is no evaluation of whether the Veteran has the disability he is claiming, i.e., Eustachian tube dysfunction. Thus, the Veteran should be provided with another ENT examination with proper evaluation of Eustachian tube functioning (or dysfunctioning). Finally, with respect to the initial rating claim for migraine headaches, the Veteran filed a timely notice of disagreement with an October 2008 rating decision that assigned an initial rating of 30 percent for migraine headaches, effective February 10, 2008. In April 2010, the RO granted an increased rating of 50 percent for migraine headaches, effective February 10, 2008. The RO noted in the rating that decision that this grant was considered a total grant of the benefit sought on appeal and indicated that the Veteran's notice of disagreement was considered resolved. Although 50 percent is the highest schedular rating available for migraine headaches under 38 C.F.R. § 4.124a, Diagnostic Code 8100, and the Veteran's description of his migraines meets the criteria for a 50 percent rating, the Veteran never specifically limited himself to a 50 percent rating in any of his statements. If the Veteran does not specifically limit himself to a particular rating, he is presumed to be seeking the highest rating available for a disability, i.e., 100 percent. AB v. Brown, 6 Vet. App. 35 (1993). While 50 percent is the highest schedular rating for migraine headaches, the Veteran could possibly receive higher ratings based on an extraschedular rating. One of the Veteran's arguments for why he should receive a rating higher than 30 percent was that he had to quit working as a cardiologist due to his migraines. Marked interference with employment is one of the factors used to consider whether entitlement to an extraschedular rating is warranted under 38 C.F.R. § 3.321(b). For this reason, the Veteran's initial rating claim for migraine headaches is not considered fully satisfied and the RO should issue the Veteran a statement of the case, which addresses this issue. 38 U.S.C.A. § 7105; 38 C.F.R. §§ 19.26, 19.29, 19.30; Manlincon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following action: 1. Arrangements should be made to obtain any rheumatology VA treatment records at the VAMC in Cincinnati, Ohio, of the Veteran related to arthralgia of the multiple joints, dated since September 1997. 2. Schedule the Veteran for an appropriate VA examination with an infectious disease specialist or rheumatologist to determine the nature, extent, and etiology of his arthropathy of the multiple joints including the shoulders, hands, wrists, hips, knees, ankles, neck, and lower back. If possible the examination should be scheduled during a flare-up of the Veteran's arthropathy. The examiner must review the claims file and state that the claims file was reviewed in the report. All indicated tests should be performed, and all findings reported in detail. Specifically, the VA examiner's opinion should address the following: (a) State whether the Veteran's complaints of pain in the shoulders, hands, wrists, hips, knees, ankles, neck, and lower back are attributable to a known clinical diagnosis, i.e., bursitis, tendonitis, arthritis, etc. (b) If any of the Veteran's symptoms are determined to be attributable to a known clinical diagnosis, state whether it is at least as likely as not (50 percent probability or greater) that the condition had its clinical onset during active service or is related to any in-service disease, event, or injury, including the parvovirus B19 infection in service in 1993. (c) If any of the Veteran's symptoms are not determined to be attributable to a known clinical diagnosis, state whether there is any impairment of function in the multiple joints, including the shoulders, hands, wrists, hips, knees, ankles, neck, and lower back (i.e., limitation of motion, weakness, fatigability) that at least as likely as not (50 percent probability or greater) had its clinical onset during active service or is related to any in-service disease, event, or injury, including the parvovirus B19 infection in service in 1993. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. If after conducting the examination, any of the above questions cannot be answered without resort to speculation, the examiner must state why this is so. 3. Schedule the Veteran for an ear, nose, and throat VA examination with a physician to determine the nature, extent, and etiology of his Eustachian tube dysfunction. The examiner must review the claims file and state that the claims file was reviewed in the report. All indicated tests should be performed, and all findings reported in detail. The examiner should use the necessary equipment to assess middle ear function (such as a tympanogram). Then the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the Veteran's Eustachian tube dysfunction had its clinical onset during active service or is related to any in-service disease, event, or injury. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. If after conducting the examination, any of the above questions cannot be answered without resort to speculation, the examiner must state why this is so. 4. After the requested examinations have been completed, the reports should be reviewed to ensure that they are in complete compliance with the directives of this remand. If any of the reports are deficient in any manner, it should be returned to the examiner for corrective action. 5. Issue a statement of the case to the Veteran and his representative addressing its assignation of a 50 rating for the Veteran's service-connected migraine headaches. The statement of the case should include all relevant law and regulations pertaining to the claims. The Veteran must be advised of the time limit in which he may file a substantive appeal. See 38 C.F.R. § 20.302(b). Thereafter, if an appeal has been perfected, these issues should be returned to the Board. 6. Finally, readjudicate the claims on appeal. If the benefits remain denied, issue the Veteran and his representative a Supplemental Statement of the Case and allow for a reasonable period to respond. 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 Supp. 2012). ______________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs