Citation Nr: 18154978
Decision Date: 12/03/18	Archive Date: 12/03/18

DOCKET NO. 18-23 040
DATE:	December 3, 2018
REMANDED
Entitlement for service connection for sinus disorder with deviated nasal septum is remanded.
REASONS FOR REMAND
The Veteran served on active duty in the US Army from January 1981 to July 1984 and from November 2004 to November 2006.  
This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900 (c) (2017). 38 U.S.C. § 7107 (a)(2) (2012).
Entitlement for service connection for sinus condition with deviated nasal septum
The Veteran contends that she is entitled to service connection for a sinus condition with deviated nasal septum.
A November 2017 VA Disabilities Benefits Questionnaire (DBQ) examination for sinusitis/rhinitis and other conditions of the nose, throat, larynx, and pharynx is inadequate because it presents conflicting reports of the status of the Veteran’s sinusitis.  The DBQ diagnoses the Veteran with acute sinusitis, but later gives a diagnosis of sinusitis without qualifying it as acute.  It is unclear whether the Veteran’s diagnosis is limited to acute.  Significantly, the Veteran has received treatment for sinus problems on multiple occasions.  See VA treatment records dated June 2011 and June 2014. Specifically, that the Veteran’s sinus headaches are to such a degree that the Veteran reportedly calls off from work at least once a week.  Moreover, the examination does not address the Veteran’s headaches experienced while in service and the possible relationship between the in-service headaches and current sinusitis.  Therefore, it is unclear whether the pathology is in fact acute.
Equally, the DBQ points out that while in service, the Veteran received a diagnosis of a non-traumatic deviated septum.  However, the examiner does not render an opinion as to the etiology of the deviated septum.  Rather, the examiner identifies the point in the Veteran’s in-service record where the deviated septum is noted with no further discussion. 
Accordingly, the Board finds a remand is warranted for further evidentiary development as the examination report is inadequate.  See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes to provide a medical examination or opinion, it must ensure that the examination or opinion is adequate).
The matters are REMANDED for the following action:
1. Schedule the Veteran for an appropriate VA examination to determine the severity of her sinusitis and to examine any current deviated septum, or residuals thereof. The claims folder is to be furnished to the examiner for review in its entirety. The examiner should perform any tests or studies deemed necessary. 
The examiner must specifically address the following questions with respect to sinus condition and deviated septum:
a) The examiner should indicate whether it is as least as likely as not (50 percent probability or more) that any current sinus condition and deviated septum, or residuals thereof, is related to her service, to include in-service headaches.
b) If the Veteran’s deviated septum did not begin during her period of active duty, the examiner must specify whether it is a congenital defect or disease.  The examiner must also provide an opinion as to whether the Veteran suffered from additional disability due to aggravation of the congenital disease or whether there is superimposed trauma on a congenital defect.  
The examiner is advised that the Veteran is competent to report her symptoms, treatment, and injuries, and that her reports must be taken into account in formulating the requested opinions.
A complete rationale is requested for all opinions provided.
 
MICHAEL D. LYON 
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	K. Scanlan, Associate Counsel