Citation Nr: 1342804 Decision Date: 12/24/13 Archive Date: 12/31/13 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 E. D. Anderson, 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) 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 continued to deny the claim for service connection for vocal cord dysfunction, by the October 2011 Supplemental Statement of the Case (SSOC), and returned this matter to the Board for further appellate consideration. In January 2012, August 2012, March 2013, and, most recently, in June 2013, the Board remanded this case to the AMC. The action specified in the June 2013 Remand completed, the matter has been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998). This appeal was processed using the VBMS paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. FINDING OF FACT The Veteran's vocal cord dysfunction had onset in military service. CONCLUSION OF LAW The criteria for entitlement to service connection for vocal cord dysfunction have been met. 38 U.S.C.A. §§ 101, 1110, 1111, 1112 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2013). In general, service connection requires competent and credible evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2013). A veteran who served during a period of war, or after December 31, 1946, will be considered to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable evidence demonstrates that an injury or disease existed prior to service and was not aggravated by such service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b) (2013). For defects, infirmities, or disorders not noted when the veteran is examined, accepted and enrolled for service, the burden lies with the government to show, by clear and unmistakable evidence, that the defect, infirmity, or disorder both pre-existed and was not aggravated by service. See Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). To satisfy the second requirement for rebutting the presumption of soundness, the government must show, by clear and unmistakable evidence, either that (1) there was no increase in disability during service, or that (2) any increase in disability was "due to the natural progression" of the condition. Joyce v. Nicholson, 443 F.3d 845 (Fed. Cir. 2006). The claimant is not required to show that the disease or injury increased in severity during service before VA meets both of these burdens. See VAOPGCPREC 3-2003. The Veteran asserts that he has vocal cord dysfunction related to service. Service treatment records show that the Veteran was afforded an enlistment examination in April 2003. At that time, no disability of the vocal cords was noted by the examining physician. In April 2004, the Veteran was diagnosed with a vocal cord disorder. The etiology of this disorder is unclear from the Veteran's service treatment records, although the pulmonologist examining the Veteran appears to suggest that the vocal cord dysfunction was likely the cause of the Veteran's asthma symptoms. Because of the Veteran's vocal cord dysfunction and preexisting history of childhood asthma, a Medical Board recommended that the Veteran be administratively separated from service as his condition rendered him unable to perform the physical requirements of a Marine. Diagnoses of asthma and vocal cord dysfunction were noted on the Veteran's April 2004 separation examination. Post-service, 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 ENT examiner reported that 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. 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. 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. A speech pathology evaluation was conducted at the Cleveland VA Medical Center April 20, 2012. At that time, the Veteran felt that his voice had been "cracking" and had been hoarse more frequently the past year or two. 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. Oral structures were observed to be without abnormalities. During conversational speech and reading tasks, the Veteran's 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. 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. In August 2013, a new VA medical opinion was obtained. The VA nurse practitioner concluded that the Veteran has a current vocal cord dysfunction. She opined that this condition was likely secondary to GERD and since there was no evidence of any GERD in service, the Veteran's vocal cord dysfunction less likely than not had onset in service. Unfortunately, the VA examiner failed to discuss the fact the Veteran was actually diagnosed with a vocal cord dysfunction in service nor did she discuss whether the Veteran's vocal cord dysfunction was caused or permanently aggravated by the Veteran's service connected asthma. Based on all the above evidence, the Board finds that entitlement to service connection for vocal cord dysfunction should be granted. Vocal cord dysfunction was not noted on the Veteran's enlistment examination. Accordingly, he is presumed to have been in sound condition at that time. There is no clear and unmistakable evidence to rebut the presumption of soundness. During service, in April 2004, the Veteran was examined and treated for vocal cord dysfunction. On separation examination, vocal cord dysfunction was among the diagnoses. After service, the Veteran reported having continuous problems with his vocal cords. The Veteran is competent to report voice issues to include cracking and hoarseness. Further, his claims of ongoing symptoms have been consistent and he is deemed credible. VA examinations, beginning in 2010 through 2013, document symptoms such as a cracking voice and hoarseness. Vocal cord dysfunction was noted, to include lazy vocal cords. Although an examiner in 2013 attributed vocal cord dysfunction to non-service-connected GERD, this examiner did not take into account pertinent details of the Veteran's case, to include in-service symptoms as a well a diagnosis. Given the service treatment records substantiating the initial diagnosis in service, the probative evidence of continuous symptoms after discharge, and the current diagnosis the Board will accord the Veteran the benefit of the doubt. Service connection for vocal cord dysfunction is granted. ORDER Entitlement to service connection for vocal cord dysfunction is granted. ____________________________________________ K. Parakkal Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs