Citation Nr: 18157711 Decision Date: 12/14/18 Archive Date: 12/13/18 DOCKET NO. 14-42 336 DATE: December 14, 2018 REMANDED Service connection for residuals of an in-service septoplasty for a deviated nasal septum is remanded. Service connection for obstructive sleep apnea, to include as secondary to an in-service septoplasty, is remanded. REASONS FOR REMAND The Veteran had active service from June 1974 to August 1994. This case is before the Board of Veterans’ Appeals (Board) on appeal from a Department of Veterans Affairs (VA) Regional Office (RO) rating decision dated June 2010. The Veteran originally requested a Board hearing in Washington, D.C., but withdrew that request in a writing submitted in March 2018. The Board finds remand is necessary because the various claims asserted by the Veteran relating to his in-service septoplasty are inextricably intertwined and the various VA examinations the Veteran has undergone are individually and collectively inadequate, necessitating addendum medical opinions. The Veteran was diagnosed in April 1977 with a deviated septum that deflected to the left with total obstruction. He underwent a septoplasty in May 1977 to straighten the septum. The Veteran’s August 1994 service exit examination noted his septum deviated to the right. The Veteran’s private treatment records show that in August 2005, he underwent an examination by his private physician, who noted the Veteran had “marked” septal deviation to the right, which was followed by a CT scan that showed right nasal septal deviation described as “mild” by the CT scan radiologist. The Veteran’s physician diagnosed him with nasal allergies, chronic pansinusitis, and deviated nasal septum. In addition, following a private sleep study, the Veteran was diagnosed in December 2005 with obstructive sleep apnea. In June 2009, the Veteran asserted his original claims for service connection for residuals of the in-service septoplasty, and for obstructive sleep apnea, to include as secondary to the in-service septoplasty, which the RO denied and are currently before the Board on appeal. In January 2018, during the pendency of the appeal, the Veteran filed additional claims for service connection for a deviated septum; obstructive sleep apnea aggravated by deviated nasal septum; recurrent epistaxis (to include as secondary to deviated septum); and anosmia, hyposmia, and hypogeusia (claimed as seeking special monthly compensation for those conditions). In his January 2018 statement in support of those claims, he asserted his obstructive sleep apnea was due, in part, to his sinusitis. In a rating decision dated May 2018, the RO denied service connection for epistaxis, and for anosmia, hyposmia, and hypogeusia, and advised the Veteran his claims for a deviated septum and obstructive sleep apnea were part of this appeal. The Veteran has complained of at least four different conditions that are potential residuals of his in-service septoplasty: deviation of his septum to the right (established as part of his service exit physical), recurrent nose bleeds (epistaxis), sinusitis/rhinitis, and obstructive sleep apnea. The Veteran’s VA examinations have not fully addressed these conditions, their potential interrelatedness, and the various theories under which they could be service connected. In general terms, addendum medical opinions are needed, in the first instance, on the issue of whether the Veteran’s septal deviation to the right, sinusitis/rhinitis, and epistaxis are etiologically related to his service, to include as residuals of his in-service septoplasty. Addendum medical opinions are also needed as to whether the Veteran’s septal deviation to the right, sinusitis/rhinitis, and epistaxis are proximately due to, the result of, or aggravated by one or more of each other condition. Finally, an addendum medical opinion is needed as to whether the Veteran’s obstructive sleep apnea is aggravated by any of those other conditions. The RO then needs to readjudicate the Veteran’s septal deviation to the right, sinusitis/rhinitis, and epistaxis for direct service connection, and, to the extent any of those conditions are entitled to direct service connection, each remaining non-service connected condition needs to be evaluated for secondary service connection as proximately due to, the result of, or aggravated by each service-connected condition. More specifically, the record shows the Veteran’s nasal septum deviated to the right upon leaving service. This condition could be considered a residual of the in-service septoplasty. However, none of the Veteran’s VA examinations addressed this condition. An addendum VA opinion is needed as to whether it is at least as likely as not the Veteran’s currently-diagnosed septal deviation to the right is etiologically related to his in-service septoplasty. Next, the Veteran’s service medical records contain numerous entries regarding complaints of recurrent nose bleeds (epistaxis) beginning November 1979. Although these were attributed during service to varicose veins in the Kiesselbach’s area of his nose, there remains an unanswered medical question as to whether that condition is a residual of the in-service septoplasty. Moreover, although the Veteran’s February 2018 VA examination established a positive nexus between his nose bleeds and his service, the examiner did not note a current diagnosis of epistaxis. Further, the rationale for the opinion, that onset of the condition was during service, as “evidence of treatment and care [is documented] in [service] medical record page 175,” is insufficiently detailed to permit review of the specific medical records referenced, as the Veteran’s service medical records are not numbered in such a way as to identify which page the examiner was referring to as “page 175”. An addendum medical opinion is needed to clarify whether the Veteran has a current diagnosis of recurrent epistaxis, and if so, the basis for the positive nexus opinion so that it can be fully reviewed and evaluated. In addition, to the extent not addressed by the foregoing, an addendum medical opinion is needed as to whether the Veteran’s recurrent epistaxis (if any) is etiologically related to his in-service septoplasty, or to his currently non-service connected sinusitis/rhinitis. Next, the Veteran’s service medical records show he was diagnosed in service with allergic rhinitis. The Veteran’s February 2018 VA examination diagnosed current chronic sinusitis and allergic rhinitis, but the examiner did not offer any opinion on the etiology of those conditions. As such, although the January 2017 VA examiner opined the Veteran’s breathing trouble is mainly due to his symptoms of nasal congestion and allergic rhinitis, and that those conditions are not due to a deviated nasal septum, no VA examiner has opined on whether the Veteran’s sinusitis and rhinitis are etiologically related to the in-service septoplasty. Thus, either or both of those conditions are potentially a septoplasty residual. In addition, there is a medical question as to whether the Veteran’s chronic sinusitis and/or allergic rhinitis are etiologically related to his epistaxis, which the February 2018 VA examiner opined was at least as likely as not related to service. Thus, both conditions are also potentially eligible for secondary service connection. Finally, the Veteran has claimed his obstructive sleep apnea is proximately due to, the result of, or aggravated by his sinusitis and deviated septum. The Veteran underwent a VA examination for his sleep apnea claim in April 2010, but the examiner did not offer an opinion as to whether his condition was etiologically related to service as none was requested. The Veteran underwent another VA examination for his sleep apnea claim in January 2017, and the examiner opined his obstructive sleep apnea is less likely than not proximately due to or the result of the Veteran’s in-service septoplasty because septoplasty due to deviated septum cannot cause sleep apnea, sleep apnea is totally due to different etiology in the hypopharyngeal / laryngeal region and not in the nasal area, and that a deviated septum can cause trouble breathing but not sleep apnea. However, the examiner did not opine whether the Veteran’s obstructive sleep apnea was aggravated by his septal deviation to the right, his sinusitis/rhinitis, or epistaxis. The matters are REMANDED for the following action: 1. Regarding the Veteran’s nasal septum deviation to the right, obtain an addendum medical opinion, preferably from the same examiner who conducted the January 2017 VA examination (although this is not required). If the examiner finds it appropriate, a new examination should be done. After a review of the claims file and completion of any examination report, the examiner should respond to the following: (a.) Does the Veteran have a current diagnosis of a deviated nasal septum? (b.) If the Veteran has currently-diagnosed deviated nasal septum, is it at least as likely as not (i.e., at least a 50 percent probability) that the condition is etiologically-related to his in-service septoplasty or otherwise began during service? 2. DO NOT proceed with the following instructions until the foregoing addendum medical opinions have been completed and associated with the claims file. 3. Regarding the Veteran’s asserted recurrent epistaxis, obtain an addendum medical opinion, preferably from the same examiner who conducted the February 2018 VA examination (although this is not required). If the examiner finds it appropriate, a new examination should be done. After a review of the claims file and completion of any examination report, the examiner should respond to the following: (a.) Does the Veteran have a current diagnosis of recurrent epistaxis? (b.) If the Veteran has currently-diagnosed recurrent epistaxis, is it at least as likely as not (i.e., at least a 50 percent probability) the condition was incurred in or caused by an in-service injury, event, or illness? The examiner should address the Veteran’s in-service septoplasty as well as the multiple in-service treatments for nosebleeds. (c.) If the Veteran has currently-diagnosed recurrent epistaxis, is it at least as likely as not (i.e., at least a 50 percent probability) that the condition was caused or aggravated (permanently worsened) by the Veteran’s currently-diagnosed chronic sinusitis or allergic rhinitis? 4. Regarding the Veteran’s currently-diagnosed chronic sinusitis, obtain an addendum medical opinion, preferably from the same examiner who conducted the February 2018 VA examination (although this is not required). If the examiner finds it appropriate, a new examination should be done. After a review of the claims file and completion of any examination report, the examiner should respond to the following: (a.) Is the Veteran’s currently-diagnosed chronic sinusitis at least as likely as not (i.e., at least a 50 percent probability) the incurred in or caused by an in-service injury, event, or illness? The examiner should address the Veteran’s in-service septoplasty. (b.) Is it at least as likely as not (i.e., at least a 50 percent probability) that the Veteran’s currently-diagnosed chronic sinusitis was caused or aggravated (permanently worsened) by the Veteran’s currently-diagnosed recurrent epistaxis (if any) or allergic rhinitis? 5. Regarding the Veteran’s currently-diagnosed allergic rhinitis, obtain an addendum medical opinion, preferably from the same examiner who conducted the February 2018 VA examination (although this is not required). If the examiner finds it appropriate, a new examination should be done. After a review of the claims file and completion of any examination report, the examiner should respond to the following: (a.) Is the Veteran’s currently-diagnosed allergic rhinitis at least as likely as not (i.e., at least a 50 percent probability) the incurred in or caused by an in-service injury, event, or illness? The examiner should address the Veteran’s in-service septoplasty. (b.) Is it at least as likely as not (i.e., at least a 50 percent probability) that the Veteran’s currently-diagnosed allergic rhinitis was caused or aggravated (permanently worsened) by the Veteran’s currently-diagnosed recurrent epistaxis (if any) or chronic sinusitis? 6. DO NOT proceed with the following instructions until the foregoing addendum medical opinions have been completed and associated with the claims file. 7. Regarding the Veteran’s currently-diagnosed obstructive sleep apnea, obtain an addendum medical opinion, preferably from the same examiner who conducted the January 2017 VA examination (although this is not required). If the examiner finds it appropriate, a new examination should be done. After a review of the claims file and completion of any examination report, the examiner should respond to the following: (a.) Is it at least as likely as not (i.e., at least a 50 percent probability) that the Veteran’s obstructive sleep apnea was caused or aggravated (permanently worsened) by any of the following conditions: (i) Any currently diagnosed deviated nasal septum; (ii) recurrent epistaxis (if any); (iii) chronic sinusitis; or (iv) allergic rhinitis 8. A complete rationale for all opinions rendered is required. References to medical treatment records should be specific (e.g., source, month and year). If the medical professional is unable to provide any required opinion, he or she should explain why. If he or she cannot provide an opinion without resorting to mere speculation, he or she must provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Leamon, Associate Counsel