Citation Nr: 1620363 Decision Date: 05/18/16 Archive Date: 05/27/16 DOCKET NO. 06-17 592 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to a rating in excess of 10 percent for right ear otitis media. 2. Entitlement to a compensable rating for neurological pathology associated with otitis media and cholesteatoma prior to March 14, 2007 and in excess of 10 percent thereafter. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Dan Brook, Counsel INTRODUCTION The Veteran served on active duty from July 1974 to May 1976. This matter is on appeal from rating decisions in February 2005 and October 2008 by the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California. In pertinent part, the February 2005 rating decision granted service connection for numbness of the right side of the face and assigned a noncompensable rating effective May 19, 2004. In pertinent part, the October 2008 rating decision continued a 10 percent rating for right ear otitis media with occasional otitis externa with chronic pain and continued the noncompensable rating for numbness of the right side of the face. In an April 2014 rating decision, the rating for numbness of the right side of the face was increased to 10 percent, effective March 14, 2007, with the disability being recharacaterized as trigeminal neuralgia. The Veteran testified before the undersigned Veterans Law Judge in March 2015. A transcript of the hearing is of record. In an April 2015 decision, the Board in pertinent part, denied a rating in excess of 10 percent for otitis media; a compensable rating for associated neurological pathology prior to June 17, 2011 and a rating in excess of 10 percent for this disability thereafter. The Veteran appealed. The Board also remanded claims for service connection for psychiatric disorder and for entitlement to a TDIU. In a November 2015 order, the Court of Appeals for Veterans' Claims (Court) upheld a joint motion of the parties and remanded the claims denied by the April 2015 above back to the Board for action consistent with the joint motion, delaying action on the TDIU issue. In a November 2015 decision, the Appeals Management Center granted service connection for an acquired psychiatric disorder and assigned a 30 percent rating effective May 28, 2004 and a 50 percent rating effective February 25, 2014. The Board notes that the agency of original jurisdiction has not yet returned the appeal for entitlement to a TDIU to the Board. However, given that this claim may be considered as part and parcel of the claims for increase currently before the Board and given that a favorable decision may be rendered, the Board considers the this TDIU claim as currently before it. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). FINDINGS OF FACT 1. The rating the Veteran receives for otitis media is the highest schedular rating allowable under the pertinent diagnostic code, and no other diagnostic code allows for a higher rating. 2. The Veteran's otitis externa is reasonably shown to involve swelling, dry and scaly or serous discharge and itching requiring frequent and prolonged treatment. 3. Prior to June 17, 2011, the Veteran's associated neurological pathology was manifested by impairment compatible with severe incomplete paralysis of the 7th cranial (i.e. facial) nerve; complete paralysis was not shown. 4. From June 17, 2011, the Veteran's associated neurological pathology was manifested by impairment compatible with complete paralysis of 7th cranial (i.e. facial) nerve. 5. The Veteran has been found to exhibit skull bone loss resulting from his multiple ear surgeries that cover an area smaller than that covered by a 25 cent piece (i.e. a quarter). 6. The Veteran's combination of service-connected disabilities meet the schedular criteria for a TDIU and are reasonably shown to render him unable to secure and follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for otitis media have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.31, 4.85, 4.86, 4.87, Diagnostic Codes (Code) 6200 (2015). 2. The criteria for a separate 10 percent, but no higher, rating for otitis externa have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.31, 4.85, 4.86, 4.87, Code 6210 (2015). 3. Prior to June 17, 2011, the criteria for a 20 percent, but no higher rating, for neurological pathology associated with otitis media and cholesteatoma have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.120, 4.123, 4.124, 4.124a, Code 8205 (2015). 4. From June 17, 2011, the criteria for a 30 percent but no higher rating for neurological pathology associated with otitis media and cholesteatoma have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.120, 4.123, 4.124, 4.124a, Code 8205 (2015). 5. Resolving any reasonable doubt in the Veteran's favor, the criteria for a separate 10 percent rating for minimal skull bone loss have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.3, 4.71a, Code 5296 (2015). 6. The criteria for a TDIU have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.3, 4.16, 4.18, 4.19 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Analysis Increased Ratings This is an complex disability with many possible rating codes that could address the Veteran's problem. The Board will endeavor to address this issue completely. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. See 38 C.F.R. § 4.1 (2014). Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. Part 4 (2014). While the Board typically considers only those factors contained wholly in the rating criteria, it is appropriate to consider factors outside the specific rating criteria when appropriate in order to best determine the level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436 (2002); Massey v. Brown, 7 Vet. App. 204, 208 (1994). Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Otitis Media The Veteran currently receives a 10 percent rating for otitis media under 38 C.F.R. § 4.87, Codes 6200 and 6210. This is the highest schedular rating allowable for this disability. The Board notes that a higher rating may be warranted for more severe symptoms of Meniere's disease under Code 6205. However, there is no indication that the Veteran has ever been diagnosed with this disorder. Therefore, this diagnostic code is not for application. The Board has also considered whether a separate rating is warranted under Codes 6200 and 6210, for otitis externa. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not "duplicative of or overlapping with the symptomatology" of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). In this case, the Veteran has experienced periodic discharge from the ear, along with instances of swelling and has reported experiencing constant itching (i.e. pruritus) on at least one occasion. He's also received a number of treatments, which appear to have been for otitis externa symptomatology, as removal of debris from the external auditory canal was involved. Additionally, he has been instructed to employ regular self-care of these symptoms. Consequently, resolving any reasonable doubt in the Veteran's favor, a separate 10 percent rating is warranted for otitis externa. 38 C.F.R. §§ 4.87, Code 6210. This is also the maximum schedular rating available rating under this Code. Associated nerve impairment When a veteran is service-connected for otitis media, mastoiditis or cholesteatoma (or any combination thereof) under 38 C.F.R. § 4.87, Code 6200, VA must also consider whether separate ratings are warranted for any associated complications, to include hearing loss, tinnitus, facial nerve paralysis and bone loss. As noted above, the February 2005 rating decision granted service connection for numbness of the right side of the face and assigned a noncompensable rating effective May 19, 2004. This allowance was based on the numbness being associated with the Veteran's service-connected otitis media and status post cholesteatoma. This disability was subsequently recharacterized as trigeminal neuralgia based on the findings of a February 2014 VA examination. For the period prior to March 14, 2007, the Veteran has been assigned a nocnompensable rating for this disability under 38 C.F.R. § 4.124a, Code 8205 (addressing paralysis of the 5th, or trigeminal, cranial nerve). From March 14, 2007, a 10 percent rating has been assigned under this Code. Also, as mentioned above, the ratings schedule specifically identifies "facial nerve paralysis" as an associated complication of otitis media and cholesteatoma (both conditions suffered by the Veteran). Consequently, the Board must consider whether it is appropriate to rate the Veteran's associated neurological pathology under Code 8207. Under this Code, moderate incomplete paralysis of the facial nerve (i.e. cranial nerve 7) warrants a 10 percent disability rating, severe incomplete paralysis of the nerve warrants a 20 percent disability rating, and complete paralysis of the nerve warrants a 30 percent disability rating. 38 C.F.R. § 4.124a. A note following this Code indicates that the rating assigned is dependent upon the relative loss of innervation of facial muscles. At a March 2004 VA examination, the Veteran complained of constant pain, pressure and fullness in the right ear area, with numbness behind the area of the ear where he had his incision for his mastoid surgery. He also reported explosive episodes of shooting pain in the right ear that happened about every two weeks that was quite severe. He was taking Vicodin for the pain but reported that this did not give him total relief. Examination of the right ear showed normal postauricular incision scar tissue with numbness in the postauricular and super- auricular region. At a June 2006 VA examination, the Veteran again complained of numbness and otalgia in the right ear. It was noted that he had sharp pain present in his ear canal as well as a general sense of discomfort in the post-auricular region. He reported that the canal pain was always present and he was currently taking Tylenol 3 for it. The Veteran indicated that when the pain was severe and he could not control it, he would crawl on the floor and begin crying. The post-auricular sense of discomfort was mostly present all day every day. Additionally, he reported experiencing shooting sharp pains across the incision area from previous mastoidectomy. Physical examination showed that the post-auricular area was notable for an incision and prior mastoidectomy. There were no masses or tenderness to palpation over this area. Within the ear canal, there was an anterior tympanic membrane perforation with a visible metallic prosthesis. Cranial nerves 3, 4, 5, 6, 7, 9, 10, 11 and 12 were intact. The examiner commented that it was likely that the Veteran was experiencing severe chronic pain on the right side of his face based on his perception. However, it was unlikely that the pain was solely a result of his prior ear surgery or ear-related disease. The examiner suspected that the Veteran's pain was multifactorial and as the Veteran stated himself, significantly related to his past medical history, including anxiety, depression and pain medication dependence. At a February 2007 VA otolaryngology visit, the examining medical professional noted that the Veteran had severe temporal mandibular joint (TMJ) laxity and that in the TMJ area, he was able to induce the same facial pain that the Veteran had been complaining of since 1997. During a March 5, 2007 medical visit, the Veteran was seen for follow-up for chronic otalgia. It was noted that this pain had improved since the Veteran started taking Neurontin on March 2nd. The medicine had mostly helped alleviate the sharp and shooting pain but the Veteran still experienced numbness, tingling and aching. No bothersome side effects from the Neurontin were noted. Subsequently, during a June 2007 ENT visit; the Veteran reported that he was optimistic because gabapentin had been helping his neuropathic pain, resulting in a reduction in both frequency and severity. At an October 2007 VA general medicine visit, the Veteran reported chronic right ear and neck pain that radiated into the right arm and occasionally to the right leg. He noted that he was taking multiple pain medications for this symptomatology and that taking the combination of Vicodin, Venflaxine and Zolmitriptan gave him maximum relief and allowed him to perform his daily work or physical activity. During an August 2008 VA ENT visit, the Veteran reported some persistent post-auricular shooting pain with some radiation along the TMJ. At a December 2008 VA ENT examination, the Veteran reported chronic pain in the right facial and ear area. He was currently taking medication, which controlled the pain somewhat but it was always present to some degree. Additionally, he reported a sensation of numbness around his right ear going into his right temporal area. The pertinent diagnosis was right chronic otitis media status post surgeries including radical mastoidectomy with chronic pain. The examiner also noted that the Veteran's pain interfered with his sleep pattern. At a December 2008 VA neurological examination, the Veteran reported that he had initially had numbness to the temple area just superior to the right auricle. Over time and subsequent surgeries, the area of numbness had increased and he currently had constant throbbing pain in the ear canal with intermittent shooting/electrical pains to the anterior, posterior and superior of the ear that were startling and painful enough that he would call out. He reported that these pains would last moments and then resolve, which was embarrassing for him. He also reported that the pain prevented him from sleeping. The Veteran was currently taking Tylenol with codeine; gabapentin and amitriptyline for his pain and sleep problems. Physical examination of the neurological system showed that cranial nerves II to XII were intact and equal bilaterally with exception of the right facial sensory nerve. The Veteran's light touch involving this nerve was tested with a 10 mg monofilament and showed loss of light touch sensation to the area surrounding the right ear and anterior to the aspect of the right eyelid, including the lateral aspect of the zygomatic/buchal area of the face. The examiner diagnosed the Veteran with numbness and neuropathic pain to the right ear and right side of the face only partially controlled by narcotics and gabapentin. At a September 2009 visit with a VA neurology medical student and VA neurologist, pursuant to a medical referral for suspected trigeminal neuralgia, the Veteran described facial and head pain localized mostly at the top 1/3 of his head. He said the pain usually started with a swelling pressure in the right ear. The Veteran reported that his current pain medications helped reduce his pain by about 40 percent though he still suffered significantly. Cranial nerve examination by the medical student showed reduced sensitivity to light touch and cold metal on the right in the cranial nerve V1 and V2 regions. The Veteran complained of pain upon light touching of the V1 region and there was good muscle strength on jaw closing and opening. Examination of the VII cranial nerve showed symmetry and strength noted with forehead wrinkling, eye closing, cheek puffing and smiling. The medical student noted that the Veteran was suffering from debilitating radiating facial and head pain across the upper 1/3 of his head that was partially responsive to carbamazepine and that he was also suffering from significant psychosocial issues secondary to the pain. The resident noted that the examination findings were suggestive of nerve and tissue damage in the opthalmic division of the trigeminal nerve and that differential diagnoses included atypical facial pain due to nerve and soft/bony tissue damage secondary to multiple surgeries, other nerve etiology such as trigeminal neuralgia and migraine headache. In an addendum, the VA neurologist noted that the Veteran appeared to have atypical facial pains status post ear surgery. At a subsequent January 2010 neurology visit, physical examination by a medical resident and concurred with by a VA neurologist showed that all cranial nerves were intact except for cranial nerve 8, where the Veteran suffered severe hearing loss on the right. The diagnostic assessment was history of cholesteatoma surgeries and subsequent facial and head pain. At a June 17, 2011 VA examination, the Veteran reported increased facial numbness and weakening. Physical examination showed exquisite pain in the right ear. The examiner noted that there were signs of nerve paralysis and skull bone loss. Specific examination of the cranial nerve VII, the facial nerve, showed asymmetry on the right side of the face, weak eyebrow lifting, week teeth showing, weak closing eyes to resistance, weak frowning, and normal tearing. The pertinent diagnosis was right facial nerve paralysis. At a June 28, 2011 otolaryngology consultation, the examining ENT noted that the Veteran's ear was in need of routing cleaning, otherwise it seemed to be a good post-operative result. The post-auricular scar and mastoid bone defect were noted as is typical following the surgery. The ENT found that facial nerve function was normal and sensation was intact except for some hypesthesia about the pinna, which was typical following radical mastoid surgery. In pertinent part, the ENT diagnosed the Veteran with otalgia. Finally, at a VA examination in February 2014, the Veteran again complained of pain and numbness. Physical examination of the right ear showed a normal external ear, normal ear canal and a perforated tympanic membrane. The examiner found that the Veteran was suffering from trigeminal nerve neuralgia. He noted that this condition was manifested by moderate intermittent pain in the upper face, eye or forehead and mid face and moderate numbness of the upper face, eye and/or forehead, mid face and lower face. Muscle strength testing of cranial nerves V (i.e. trigeminal) through XII was normal. Sensory examination showed decreased sensation in the right upper face, mid face and lower face. The examiner indicated that the sensory findings were consistent with trigeminal nerve distribution, not facial motor weakness, as previously noted in the June 2006 VA examination. Overall, the examiner found that the impairment of the cranial nerve was manifested by incomplete moderate paralysis and the examiner diagnosed the Veteran with trigeminal neuralgia. Considering the appropriate diagnostic code to employ to rate the Veteran's associated neurological disability, the December 2008 VA examiner specifically found on physical examination that all cranial nerves were intact except the facial nerve, which exhibited sensory impairment. Also, the June 2011 VA examiner specifically found paralysis of the facial nerve and did not find any dysfunction of the trigeminal nerve. Additionally, the June 2006 VA examiner actually found that cranial nerves 5 and 7 were both intact (along with the other nerves tested); that while the Veteran was experiencing severe chronic pain on the right side of his face, it was unlikely that the pain was solely a result of his prior ear surgery or ear-related disease; that he suspected that the Veteran's pain was multifactorial; and as the Veteran stated himself, significantly related to his past medical history, including anxiety, depression and pain medication dependence. Further, at the February 2007 VA otolaryngology visit, the examining medical professional found that the Veteran's longstanding facial pain was actually related to severe temporal mandibular joint (TMJ) laxity, a disability for which the Veteran is not service-connected. Moreover, the rating schedule specifically recognizes that damage to the facial nerve (e.g. paralysis) can be a specific complication of otitis media, mastoiditis and/or cholesteatoma but does not recognize damage to the trigeminal nerve as such a complication. See 38 C.F.R. § 4.87, Code 6200. Notably, the February 2014 VA examiner found that the Veteran had trigeminal nerve impairment rather than facial nerve impairment and appeared to find that this neurological impairment was associated with his past surgeries. However, he did not provide any explanation of how such neurological damage would have occurred. Also, the September 2009 VA neurology student and neurologist found some trigeminal nerve pathology and included trigeminal neuralgia as an initial differential diagnosis. However, this finding was not firm and these medical professionals also did not provide any specific opinion as to how the trigeminal nerve pathology found by physical examination could have been caused by the ear surgeries the Veteran received. There is also no indication that they reviewed the claims file, including the reports providing specific information concerning the nature and temporal sequence of the past surgeries. Consequently, considering the pertinent medical documentation as a whole, the evidence weighs in favor of a finding that the neurological impairment associated with the Veteran's otitis media and cholesteatoma with multiple surgeries is appropriately considered as facial nerve impairment under Code 8207 and weighs against a finding that this disability involves impairment of the trigeminal nerve under Code 8205. In so doing, the Board emphasizes that in determining the appropriate ratings to be assigned under Code 8205, it is crediting the Veteran's reporting that his pain in and around the ear area has been and continues to be severe in nature and this pain, along with his numbness and tingling, results from the surgeries he received for his service-connected otitis media/cholesteatoma. However, to the extent that the Veteran has other neurological impairment of the facial area, beyond that involving the facial nerve, the weight of the evidence indicates that it is a result of non-service connected disabilities, including TMJ or other pathology. Accordingly, the Board does not have a basis for assigning any rating for it under Code 8205. Prior to June 17, 2011, the Veteran's associated nerve impairment is reasonably shown to be compatible with severe incomplete paralysis. In this regard, he was reasonably shown to exhibit severe pain in and around the right ear area affected by his otitis media, cholesteatomas and surgeries and at maximum, such pain can be rated as equal to severe incomplete paralysis. See 38 C.F.R. § 4.123. A higher, 30 percent rating is not warranted as complete paralysis of the facial nerve was not shown. In particular, the June 2006 VA examiner found that the nerve was intact and December 2008 VA examiner found sensory impairment of the nerve but did not find any significant motor impairment. 38 C.F.R. § 4.124a, Code 8207. At the June 17, 2011 VA examination, the examiner found that the Veteran had paralysis of the facial nerve. Thus, resolving any reasonable doubt in the Veteran's favor, complete paralysis of the facial nerve has been established as of this date. Consequently, assignment of a 30 percent rating is warranted. A schedular rating in excess of 30 percent is not warranted as 30 percent is the maximum rating available under Code 8207. The June 2011 VA examiner did also indicate that there were signs of skull bone loss. Also, a February 2014 VA ENT examiner specifically noted skull bone loss that was smaller than a quarter. There does not appear to be any explicit finding of record to the contrary (i.e. a finding that the Veteran has not suffered any loss of bone of the skull due to his multiple ear surgeries). Also, there is no indication or allegation in the record of skull bone loss that does cover an area as large as a quarter (i.e. a 25 cent piece). Accordingly, resolving reasonable doubt in the Veteran's favor, a 10 percent but no higher rating is warranted for skull bone loss involving an area smaller than a quarter. See 38 C.F.R. § 4.71a, Code 5296. The Board has also considered whether a separate rating could be assigned for the Veteran's post-surgical scarring. However, to the extent that the Veteran's has pain from such scarring, this is accounted for in the rating for his associated neurological impairment and assignment of a separate rating for it would amount to impermissible pyramiding. 38 C.F.R. § 4.14. Moreover, the scarring is not otherwise shown to warrant a compensable rating under applicable diagnostic codes. See 38 C.F.R. § 4.118, Codes 7800-7805. Regarding tinnitus and sensorineural hearing loss, the Board notes that increased ratings were considered for these disorders when issuing the October 2008 rating decision. However, the Veteran did not submit a notice of disagreement to these issues. As a consequence, while they have been adequately addressed, they are not on appeal for the Board's consideration. This analysis is also consistent with the more recent joint motion, which did not consider either of the ratings for these disabilities as being on appeal. The joint motion did find that the April 2015 Board decision had erred by finding that the Veteran was not entitled to a compensable rating for his associated neurological impairment prior to June 17, 2011 when in fact, a 10 percent rating had already been awarded to him effective March 14, 2007. Through the current higher ratings assigned, this issue has been ameliorated. The appellant's attorney has also specifically noted that the Veteran exhibits sharp pain in his ear canal, including constant throbbing pain with intermittent shooting pain and notes his report made during the June 2006 VA examination that when he couldn't control the pain and it had caused to him to crawl on the floor and begin crying while experiencing "death thoughts." Additionally, the attorney referenced the September 2009 visit with the VA neurology medical student, where the student assessed the Veteran as having debilitating radiating facial and head pain with nerve and tissue damage in the opthalmic distribution of the trigeminal nerve. However, as explained above, the Veteran's service-connected severe facial nerve pain is now appropriately accounted for by assignment of the 20 percent rating prior to June 17, 2011 for impairment compatible with severe incomplete paralysis of the facial nerve and assignment of the 30 percent rating for paralysis of the facial nerve from June 17, 2011. In this regard, even severe pain of the facial nerve, without the presence of complete paralysis may not be afforded a rating in excess of 20 percent under Code 8207 or its companion, Code 8307. See 38 C.F.R. § 4.123 (indicating that neuritis characterized by constant pain, at times excruciating, cannot be afforded a rating higher than that compatible with severe incomplete paralysis of the nerve involved). Also, as explained above, the weight of the medical evidence establishes that some of the Veteran's facial nerve pain (e.g. pain in the trigeminal nerve distribution) stems from non-service connected sources. Additionally, while there have been times when the Veteran has experienced "a debilitating level of pain", he has also been shown to have received some level of relief through the use of pain medications. Moreover, while it is clear that the Veteran's pain has negatively impacted his psychiatric functioning, including by causing sleep impairment, this negative impact is accounted for by the separate rating assigned for his psychiatric disability. For all of these reasons, the attorney's arguments do not form a basis for assigning any higher ratings for the Veteran's associated neurological impairment beyond those now assigned by the Board. In considering the appropriate disability rating, the Board has also considered the Veteran's statements. While the Veteran is fully competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, he has limited competence to identify specific level of disability of his inner ear disabilities and associated neurological impairment according to the appropriate diagnostic codes. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). On the other hand, such competent evidence concerning the nature and extent of the Veteran's inner ear disabilities has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and VA treatment records discussed above) directly address the criteria under which these disabilities are evaluated. Thus, to the extent the Veteran is asserting that he should be entitled to any higher rating for his associated neurological impairment than currently granted, the Board finds that this assertion is outweighed by the pertinent medical findings. The Board also finds that consideration for an extraschedular evaluation, a component of a claim for an increased rating, is not warranted for the Veteran's otitis media, otitis externa, associated neurological impairment or skull bone loss. Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). In considering whether an extraschedular rating may be warranted, VA must first determine whether the available applicable schedular rating criteria are inadequate because they do not contemplate the Veteran's level of disability and symptomatology. If the rating criteria are inadequate, VA must then determine whether the Veteran exhibits an exceptional disability picture indicated by other related factors such as marked interference with employment or frequent periods of hospitalization. If such related factors are exhibited, then referral must be made to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for extraschedular consideration. See Thun v. Peake, 22 Vet. App. 111 (2008). In this case, while this is a complex case, the evidence does not indicate that Veteran's disability picture is not adequately contemplated by the many applicable schedular rating criteria discussed above. Specifically, the Board has reviewed all of his relevant symptoms related to the issues on appeal, including pain, numbness, motor impairment, minimal bone loss, swelling, discharge, itching and recurrent infection and concludes that there are no symptoms that were not able to be addressed by the applicable diagnostic codes. See Mittleider v. West, 11 Vet. App. 181 (1998). In this regard, the Veteran's symptoms of pain, numbness and subsequent motor impairment are appropriately addressed by the neurological ratings assigned; the Veteran's chronic infections are appropriately assigned the 10 percent rating for otitis media; the Veteran's various symptoms of otitis externa, including swelling, discharge and itching are appropriately assigned the 10 percent rating for otitis externa (and in this regard, the noted debris is reasonably considered as akin to discharge) and, minimal skull bone loss is appropriately assigned the 10 percent rating for this presentation. The Veteran's attorney has argued that the Veteran experiences far worse symptoms than are "typical" for a patient with his conditions, as multiple treatment providers have described his symptoms as "atypical"; as the Veteran experiences sleep problems and suicidal ideation associated with his pain; and as the Veteran's constant pain results in him unemployable. However, as previously noted, not all of his pain is shown to result from his service-connected disability, just that found to be affecting the facial nerve and in turn, this pain has been somewhat controlled through the use of pain medication. Also, the Veteran's psychiatric disorder with sleep problems is accounted for by the separate rating assigned for psychiatric disability. Additionally, while the Veteran is shown to be generally unemployable due to his combination of service connected disabilities, he is not shown to be unemployable simply due to the pain and numbness attributable to his service-connected neurological disability. For all these reasons, as well as those discussed above, the Board finds that the schedular ratings now assigned for otitis media, otitis externa, associated neurological impairment and skull bone loss are adequate and referral for extraschedular consideration is not warranted. See Thun, 22 Vet. App. at 111; see also Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Moreover, as explained below, the Veteran now qualifies for a TDIU rating, which appropriately addresses his unemployability due to his combination of service-connected disabilities. The joint motion also required the Board to discuss the holding in Johnson v. McDonald, 762 F.3d 1362 (2014) in conjunction with the claims on appeal. Under Johnson, a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture the collective impact of all the service-connected disabilities experienced. Such a situation is not present here. As noted, the ratings assigned for otitis media, otitis externa, associated neurological impairment and skull bone loss adequately assess the nature and level of impairment resulting from each of these disabilities. Also, there is no indication or assertion that the separate ratings that have been assigned for the Veteran's service-connected depression, vertigo, hearing loss and tinnitus are inadequate. Additionally, neither the Veteran nor his representative have specifically asserted that the combination of all currently assigned individual ratings fails to capture the collective impact of all the service connected disabilities. Further, as explained below, the Veteran now qualifies for a TDIU, which affords him a total, 100 percent rating for the collective impact of his service-connected disabilities. It is unclear under what cogent foundation we should send this case for an extraschedular rating in light of the TDIU finding. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that cannot be attributed to the combined effect of his multiple conditions. Johnson, 762 F.3d 1362. TDIU Incorporating the findings above, the Veteran's current service-connected disabilities include major depression with anxiety disorder, rated 50 percent disabling, vertigo and positional vertigo, rated 30 percent disabling, facial nerve paralysis, rated 30 percent disabling, tinnitus, rated 10 percent disabling, otitis media, rated 10 percent disabling, otitis externa rated 10 percent disabling; right ear hearing loss, rated 10 percent disabling; and skull bone loss, rated 10 percent disabling. Thus, the Veteran has one service-connected disability rated 40 percent disabling or more and sufficient additional disability to bring the combined rating to 70 percent or more. Accordingly, he meets the schedular criteria for assignment of a TDIU. 38 C.F.R. § 4.16a. Also, the Veteran is reasonably shown to be unable to secure and follow a substantial gainful occupation. In this regard, in the Veteran's formal claim for a TDIU, he reported that he had last worked full time as an environmental service technician for the Palo Alto VA Medical Center (VAMC) from May 2008 to November 2008. Prior to this, he had worked full time as a custodian for Goodwill Industries from April 2002 to June 2002. Additionally, he reported that he only has an11th grade education. Also, at the December 2008 VA medical examination, the examiner opined that all of the Veteran's ear problems (i.e.) otitis media, hearing loss, chronic tinnitus and chronic labyrinthitis made him unemployable. Further, at the June 2011 VA otolaryngology consultation, the VA ENT found that the Veteran was unable to work because of his difficulty with balance and with ear pain and trouble hearing. Moreover, VA psychiatric treatment records generally show global assessment of functioning scores between 40 and 55, indicative of significant impairment in employability. Consequently, resolving any reasonable doubt in his favor, the evidence shows that the Veteran is unemployable due to his combination of service-connected disabilities. Accordingly, assignment of a TDIU is warranted. 38 C.F.R. § 4.16a. II. Due Process VA has a duty to notify and assist claimants in substantiating claims for VA benefits. See e.g. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159; Dingess v. Nicholson, 19 Vet. App. 473 (2006). In this case, the Veteran was provided notice letters informing him of both his and VA's obligations, the evidence necessary to substantiate the claim and pertinent information concerning the assignment of ratings and effective dates. Therefore, additional notice is not required and any defect in notice is not prejudicial. VA has a duty to assist a claimant in the development of a claim. This duty includes assisting the claimant in the procurement relevant treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Pertinent medical evidence has been associated with the claims file, including VA treatment records and Social Security Administration records, and the Veteran's assertions and those of his counsel are also of record and have been considered. Additionally, the Veteran has been provided with the above-summarized VA examinations. Upon review of these examination reports, the Board observes that the examiners reviewed the Veteran's past medical history, recorded his current complaints and history, conducted appropriate evaluations and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The VA examination reports are therefore adequate for the purpose of rendering a decision on appeal. 38 C.F.R. § 4.2 (2014); Barr v. Nicholson, 21 Vet. App. 303 (2007). In this regard, although the Board did not include the February 2014 VA examiner's finding of trigeminal neuralgia as part of the Veteran's service-connected disability picture for rating purposes, the examination, read in conjunction with the earlier June 2011 VA examination and the Veteran's consistent report of severe pain, was sufficiently comprehensive for rating purposes. There is no indication of additional existing evidence that is necessary for a fair adjudication of the claim that is the subject of this appeal. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist and the Board will proceed to render its decision. ORDER A rating in excess of 10 percent for otitis media is denied. A separate 10 percent rating for otitis externa is granted subject to the regulations governing the payment of monetary awards. Prior to June 17, 2011 a 20 percent but no higher rating is granted for severe incomplete paralysis of the facial nerve. From June 17, 2011, a 30 percent but no higher rating for facial nerve paralysis is granted subject to the regulations governing the payment of monetary awards. A separate 10 percent rating for skull bone loss is granted subject to the regulations governing the payment of monetary awards. A TDIU is granted subject to the regulations governing the payment of monetary awards. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs