Citation Nr: 18141321 Decision Date: 10/10/18 Archive Date: 10/10/18 DOCKET NO. 16-24 910A DATE: October 10, 2018 REMANDED Entitlement to an initial compensable rating for service-connected maxillary sinusitis is remanded. Entitlement to an initial compensable rating for service-connected anal/perianal fistula is remanded. REASONS FOR REMAND The Veteran served on active duty from December 2003 to May 2014. These matters come to the Board of Veterans’ Appeals (Board) on appeal from a rating decision dated in December 2014 by a Department of Veterans Affairs (VA) Regional Office (RO). 1. Entitlement to an initial compensable rating for service-connected maxillary sinusitis is remanded. A November 2014 VA examination documented that the Veteran had episodes of maxillary sinusitis with associated symptoms of headaches, pain of affected sinus, tenderness of affected sinus, and purulent discharge that occurred every two years. In the June 2016 substantive appeal, the Veteran asserted that since January 2016 he had at least six episodes that were characterized as incapacitating and he was on pace to have at least six non-incapacitating episodes that year. In subsequent statements, the Veteran indicates multiple instances of sinus issues per year. As the evidence indicates that the Veteran’s symptoms have increased in severity since the November 2014 VA examination, the Veteran should be provided with another examination. 2. Entitlement to an initial compensable rating for service-connected anal/perianal fistula is remanded. A November 2014 VA examination report noted that the Veteran had been given suppositories for his anal fissures and the Veteran reported occasional rectal bleeding. The examiner determined that there were no findings, signs, or symptoms attributable to the anal/perianal fissures. The Veteran reported in the June 2016 substantive appeal that he has issues with his anal/perianal fistula condition every day to include bleeding. In subsequent statements, the Veteran indicated hemorrhoids as well, based on a colonoscopy conducted in 2017. Based on the foregoing, the Board finds that the Veteran should be provided with another VA examination. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA sinus examination by an appropriate medical specialist to evaluate the severity of the Veteran’s service-connected sinus disability. The claims file must be made available to and be reviewed by the examiner in conjunction with the examination. All tests deemed necessary should be conducted and the results reported in detail. The examiner must elicit from the Veteran a detailed history of the symptoms of his sinusitis to include the type of symptoms and the frequency of such symptoms. After review of the claims file and examination of the Veteran, the examiner should discuss the severity and frequency of all symptoms related to the Veteran’s sinusitis based on the medical evidence of record, the VA examination, and the Veteran’s lay statements. The examiner should specifically comment as to the number of incapacitating episodes of sinusitis that the Veteran has experienced within a 12-month period requiring prolonged (4-6 weeks) antibiotic treatment, as well as the frequency (in terms of number of episodes in the last year) and severity of the Veteran’s non-incapacitating episodes of sinusitis characterized by headaches, pain, and purulent discharge or crusting. Also, the examiner should discuss whether the Veteran experiences nearly continuous sinusitis symptoms and whether the Veteran has had radical surgery resulting in chronic osteomyelitis. An explanation for all opinions expressed must be provided. 2. Schedule the Veteran for a VA examination by an appropriate medical specialist to evaluate the severity of the Veteran’s service-connected anal/perianal fistula. The claims file must be made available to and be reviewed by the examiner in conjunction with the examination. All tests deemed necessary should be conducted and the results reported in detail. The examiner must elicit from the Veteran a detailed history of the symptoms of his anal/perianal fistula to include the type symptoms and the frequency of such symptoms. After review of the claims file and examination of the Veteran, the examiner should discuss the severity and frequency of all symptoms related to the Veteran’s anal/perianal fistula based on the medical evidence of record, the VA examination, and the Veteran’s lay statements. In this regard, the examiner must document whether the Veteran’s anal/perianal fistula results in no leakage; constant slight leakage or occasional moderate leakage; occasional involuntary bowel movements necessitating wearing of a pad; extensive leakage and fairly frequent involuntary bowel movements; or a level of incontinence equal to complete loss of sphincter control. The examiner must also address the Veteran’s contention that he has hemorrhoids. If hemorrhoids are found at any time during the course of the appeal, the examiner must opine as to whether the hemorrhoids are a symptom of the service-connected anal/perianal fistula or are caused or aggravated by the service-connected anal/perianal fistula. An explanation for all opinions expressed must be provided. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Berry, Counsel