Citation Nr: 18112976 Decision Date: 06/21/18 Archive Date: 06/20/18 DOCKET NO. 14-41 456A DATE: June 21, 2018 ORDER Entitlement to service connection for cervical sympathetic nerve injury variously diagnosed as tachycardia/vagus nerve disorder is granted. Entitlement to service connection for global brain atrophy is granted. Entitlement to service connection for pituitary tumor rupture, to include stroke is denied. Entitlement to service connection for hypogonadism is denied. Entitlement to service connection for an arachnoid cyst (claimed as a temporal lobe cyst) is denied. Entitlement to service connection for a hernia, to include an umbilical hernia repair, is denied. REMANDED Entitlement to service connection for deviated septum (claimed as septal deviation surgery), to include residuals of septoplasty is remanded. FINDINGS OF FACT 1. The Veteran’s cervical sympathetic nerve injury variously diagnosed as tachycardia/vagus nerve disorder is related to his service connected cervical spine disability. 2. The Veteran’s global brain atrophy is related to service. 3. The preponderance of the evidence is against finding that the Veteran has pituitary tumor rupture, to include stroke due to a disease or injury in service, to include a specific in-service event, injury, or disease. 4. The preponderance of the evidence is against finding that the Veteran has hypogonadism due to a disease or injury in service, to include a specific in-service event, injury, or disease. 5. The preponderance of the evidence is against finding that the Veteran has an arachnoid cyst due to a disease or injury in service, to include a specific in-service event, injury, or disease. 6. The preponderance of the evidence is against finding that the Veteran has a hernia, to include an umbilical hernia repair, due to a disease or injury in service, to include a specific in-service event, injury, or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for cervical sympathetic nerve injury variously diagnosed as tachycardia/vagus nerve disorder are met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a); 3.310. 2. The criteria for service connection for global brain atrophy are met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 3. The criteria for service connection for a pituitary tumor rupture, to include stroke are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 4. The criteria for service connection for hypogonadism are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 5. The criteria for service connection for an arachnoid cyst (claimed as a temporal lobe cyst) are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 6. The criteria for service connection for a hernia, to include an umbilical hernia repair, are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1985 to November 1990, from September 2001 to October 2001, and from February 2003 to April 2006. This matter comes before the Board on appeal from a November 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. A travel board hearing was held in August 2016 before the undersigned Veterans Law Judge. As a preliminary matter, there was additional evidence added to the record after the issuance of the September 2014 statement of the case and October 2016 transfer of the appeal to the Board. The Board finds the additional evidence is cumulative, as it documents the Veteran’s continuing medical treatment for the disorders in which he is seeking service connection. As the additional evidence is not pertinent, meaning it does not address the nexus between the issues on appeal and the Veteran’s service, solicitation of a waiver is not necessary, as set forth in 38 C.F.R. § 20.1304(c). Service Connection Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in active military service or, if preexisting such service, was aggravated thereby. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). Generally, to establish entitlement to service connection, a veteran must show evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a causal relationship between the current disability and an in-service injury or disease. All three elements must be proved. See generally Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Alternatively, under 38 C.F.R. § 3.303(b), service connection may be established for certain chronic diseases listed under 38 C.F.R. § 3.309 (a) by either (1) the existence of such a chronic disease noted during service, or during an applicable presumption period under 38 C.F.R. § 3.307, and present manifestations of that same chronic disease; or (2) where the condition noted during service is not in fact shown to be chronic or where the diagnosis of chronicity can be legitimately questioned, then a showing of continuity of symptomatology after discharge is required to support the claim of service connection. 38 C.F.R. § 3.303 (b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, including other organic diseases of the nervous system, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C.§ 5107 (b); 38 C.F.R. §3.102; see Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for cervical sympathetic nerve injury The Veteran contends that he has a cervical sympathetic nerve injury because of a July 1987 in-service fall that resulted in a cervical spine disability. The Board notes that the Veteran is service-connected for degenerative disc disease with intervertebral disc syndrome and degenerative joint disease of the cervical spine. The existence of a present disability is established through the Veteran’s medical treatment records and examination reports produced during the course of his appeal. These records contain a diagnosis of a cervical sympathetic nerve injury, variously diagnosed as tachycardia/vagus nerve disorder. In a September 2013 private treatment letter, Dr. J. H., a neurological surgeon, indicated that he suspected that the Veteran has a vagus nerve injury as a result of cervical spine surgery. Dr. J. H. opined that the Veteran was noted to have significant tachycardia (an abnormally rapid heart rate) and required medications to maintain a normal heart rate. Dr. J. H. explained that the tachycardia medications have not allowed the Veteran to have the heart rate required to sustain significant physical activity. In a February 2014 treatment letter, Dr. J. H. explained that the Veteran suffered a fall in 1987 causing kyphosis which reduced his ability to tolerate wear and tear on his cervical discs. This caused accelerated degenerative disc disease from C3-C7 and significant exacerbation of the Veteran’s cervical spine disability. Dr. J. H. rendered the clinical assessment that the Veteran sustained a vagus nerve injury as a result of cervical spine surgery related to the Veteran’s service-connected cervical spine disability. Dr. J. H. expounded on the fact that the Veteran required two cervical surgeries to correct his cervical deformity. In the initial surgery, the intended goal was to use a large footprint graft, but Tricare did not approve the process and the Veteran underwent a cervical cadaver bone procedure. The cadaver bone subsided and revision surgery was required. Dr. J. H. pointed out the crucial fact that “somewhere in the course of the second surgery, the Veteran began to develop heart rate abnormalities and tachycardia requiring Coreg which he will take for the rest of his life.” After carefully reviewing the evidence of record, the Board finds that service connection for cervical sympathetic nerve injury, variously diagnosed as tachycardia/vagus nerve disorder, is warranted. The Veteran is currently diagnosed with tachycardia/vagus nerve disorder. The Board notes that the Veteran is service-connected for a cervical spine disability. Dr. J. H., a neurological specialist, treated the Veteran for 5 years and was aware of his medical history, conducted an in-person examination, and provided a medical nexus opinion that attributes the Veteran’s tachycardia/vagus nerve disorder to a corrective surgical spine surgery related to the Veteran’s service-connected disorder. It is well established that a medical opinion “must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.” See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). As such, when reviewing medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). The probative value of a medical opinion is generally based on the scope of the examination or review, as well as the relative merits of the expert’s qualifications and analytical findings, and the probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion. Sklar v. Brown, 5 Vet. App. 140 (1993). In this case, Dr. J. H. provided an expert medical opinion that speaks to the question at hand, mainly, whether the Veteran’s cervical sympathetic nerve injury, variously diagnosed as tachycardia/vagus nerve disorder is related to his service-connected cervical spine disability. It light of the foregoing, the Board is satisfied that the criteria for entitlement to service connection for cervical sympathetic nerve injury, variously diagnosed as tachycardia/vagus nerve disorder as secondary to service-connected cervical spine disability have been met. 38 U.S.C. 5107(b); 38 C.F.R. § 3.102. 2. Entitlement to service connection for pituitary tumor rupture, to include stroke and global brain atrophy The Veteran contends that he has a pituitary tumor rupture, namely, global brain atrophy, as a result of his service, including exposure to hazardous chemicals. The existence of a present disability is established through the Veteran’s medical treatment records and examination reports produced during the course of his appeal. These records contain a diagnosis of a pituitary tumor, variously diagnosed as pituitary apoplexy, rupture of pituitary adenoma, pituitary stroke, and cerebrovascular accident, and global brain atrophy. Service treatment records (STRs) indicate that the Veteran endorsed “yes” for tumor, growth, cyst or cancer, on his February 2006 separation examination report of medical history. However, the remaining inquiry is whether the evidence demonstrates the incurrence of a pituitary tumor rupture, to include stroke and global brain atrophy, in service or as a result of service. Upon review of the evidence, the Board concludes that the evidence of record warrants a finding that the Veteran’s global brain atrophy is related to his military service. An April 1988 Occupational Health Surveillance Questionnaire indicates that the Veteran worked as a deckhand aboard the U.S. Coast Guard Cutter (USCGC) Papaw from January 1986 to February 1988. The Veteran reported that he was exposed to paints, thinners, and asbestos. The questionnaire also indicates that the Veteran worked as an engineer for the U.S. Coast Guard and was stationed in Charleston, South Carolina from February 1987 to April 1988. The Veteran reported that he was exposed to dichloroacetic acid (DCA), antifreeze, fuel (diesel #2), toluene, paints, trichloroethane, R12 Freon, oil fire smoke, Purple-K (PKP) and battery acids. According to the Veteran, he was only issued earplugs as protective devices. A September 2009 U.S. Coast Guard Periodic Health Assessment indicates that the Veteran had a pituitary tumor that was treated with multiple medications. The examining physician endorsed “no” in assessing whether the Veteran was fully medically ready and required no follow-up examinations. A February 2010 brain magnetic resonance imaging (MRI) revealed a 2 mm focus of decreased enhancement of the left lateral pituitary gland, which could represent a tiny microadenoma or intercalated cerebrospinal fluid leak (CSF) along the edge of the gland. A November 2011 private MRI indicates that the Veteran’s global brain atrophy was mild but unusual for his age and that the cause is uncertain. There was no evidence of abnormal pituitary neuroaxis. In a September 2013 private treatment letter, Dr. J. H., a neurological surgeon, explained that the Veteran had apparent pituitary apoplexy and rupture of pituitary adenoma resulting in the need for chronic medications, including testosterone shots. Dr. J. H. noted that a brain MRI showed significant atrophy and cognitively associated memory loss. The neurological surgeon rendered the clinical assessment that the Veteran’s global brain atrophy is due to military exposure to toluene which is used extensively in paint supplies on ships, as well as for cleaning buoys. Dr. J. H. ultimately concluded that the Veteran’s global brain atrophy is associated with his long-term contact with the chemical toluene. Dr. J. H. made a similar assertion in a February 2014 letter. According to Dr. J. H., the Veteran’s global brain atrophy is greater than appropriate for his age. Dr. J. H. expounded on the fact that this is unrelated to the Veteran’s pituitary syndrome and is likely the result of toluene exposure on the USCGC Papaw. Dr. J. H. discussed the Veteran’s duties, mainly that he did significant work involving toluene during active duty and that there is a great deal of literature supporting the effects of the toxic substance (toluene). Dr. J. H. noted that the Veteran has had several MRIs which varying radiologists have agreed and confirmed that the Veteran has a greater than age-appropriate global brain atrophy. In support of his claim, the Veteran submitted a statement dated April 2014 from P. S., who served with him from 1984-1986. According to P. S., the Veteran was a seaman apprentice aboard the USCGC Papaw and assigned to the deck department were his main duties was to remove, refurbish, and replace large buoys. P.S. asserted that he witnessed the Veteran “wet and dirty from all of the barnacles and foreign matter [that he] scraped and cleaned off the buoys.” P. S. asserted that he observed the Veteran “covered in Naphtha Red Lead Pain, Green death primer, toluene and other chemicals.” P. S. further asserted that the Veteran “dealt with chemicals more than anyone else” and “did not receive any hazardous material warnings.” In the October 2014 substantive appeal (VA Form 9) and during the August 2018 Board hearing, the Veteran averred that doctors informed him that his global brain atrophy was caused by “contact with large amounts of toluene.” The Veteran contended that he was informed it “takes about a decade for atrophy to show up in the brain.” The Veteran asserted that he used toluene to clean the lead pain and other chemicals off his body daily. According to the Veteran, he “basically bathed in toluene.” The Veteran asserted that he used lead paint, “green death” and toluene daily and later found out that the products were toxic. Based upon the foregoing, the Board finds that service connection for global brain atrophy is warranted. A review of the clinical evidence of record indicates that the Veteran has currently diagnosed global brain atrophy. The Veteran reported exposure to paints, thinners, asbestos, dichloroacetic acid (DCA), antifreeze, fuel (diesel #2), toluene, trichloroethane, R12 Freon, oil fire smoke, Purple-K (PKP) and battery acids while working as a deckhand aboard the USCGC Papaw, and as a Coast Guard engineer. Most crucially, in September 2013 and February 2014, Dr. J. H., a neurological surgeon, attributed the Veteran’s global brain atrophy to his in-service exposure to toluene. According to Dr. J. H., the Veteran’s global brain atrophy is greater than appropriate for his age, is unrelated to his pituitary syndrome, and is likely the result of toluene exposure while working aboard the USCGC Papaw. In other words, Dr. J. H. attributed the Veteran’s global brain atrophy to “his long term-contact with the chemical [toluene]”. Dr. J. H.’s medical opinions are afforded significant probative value as he treated the Veteran for 5 years before rendering his clinical assessment, conducted in-personal examinations, and provided a persuasive basis for his medical opinion. Dr. J. H. explained that there is a great deal of literature supporting the effects of toluene and that varying radiologists agreed and confirmed that the Veteran’s global atrophy is greater than age-appropriate. See Stefl, supra; see also Sklar, supra. In light of the foregoing, the Board is satisfied that the criteria for entitlement to service connection for global brain atrophy have been met. 38 U.S.C. 5107(b); 38 C.F.R. § 3.102. Service connection, however, is not warranted for pituitary tumor rupture, to include stroke, because no competent evidence has linked this disorder to the Veteran’s service, to include exposure to toluene. 3. Entitlement to service connection for hypogonadism The Veteran contends that he has hypogonadism that is due to service. A December 2008 treatment note by Dr. J. H., a neurological surgeon, indicates that the Veteran has a 2 mm hypointense lesion within the left pituitary which he believes is a pituitary adenoma. The Veteran previously reported stroke-like symptoms, which Dr. J. H. believes may have been a pituitary infarction. Dr. J. H. explained that a brain MRI did not suggest an active pituitary lesion. During consultation, the Veteran expressed concern about his high cortisol level and the need to take Synthroid, testosterone, and occasionally dexamethasone. Dr. J. H. rendered the clinical assessment that the Veteran’s pituitary lesion was not the etiology of his hormonal dysfunction and that further examination was needed. On VA outpatient treatment in August 2011, the Veteran was diagnosed with hypogonadism controlled with hormone therapy. An August 2011 VA treatment note described the Veteran’s hypogonadism as a chronic problem. In a September 2013 private treatment note, Dr. J. H., opined that the Veteran had apparent pituitary apoplexy and rupture of pituitary adenoma resulting in the need for chronic medications, including testosterone shots. VA active medication lists includes testosterone cypionate, 200 mg (1ML) as early as April 2014. On VA outpatient treatment in June 2016, the Veteran was diagnosed with low testosterone (probably secondary rather than primary hypogonadism). A September 2017 VA treatment note shows that the Veteran’s edema may be 2/2 due to hypogonadism given occurrence with reduced testosterone dosing. The clinical evidence of record suggests that the Veteran’s hypogonadism may be related to his pituitary tumor disorder. The Board’s decision herein, however, denies service connection for pituitary tumor rupture, to include stroke. Thus, service connection is not warranted. 4. Entitlement to service connection for an arachnoid cyst (claimed as a temporal lobe cyst) The Veteran contends that he has an arachnoid cyst due to service. The existence of a present disability is established through the Veteran’s medical treatment records and examination reports produced during the course of his appeal. These records contain a diagnosis of an arachnoid cyst, variously diagnosed as brain cyst, benign. STRs revealed no abnormalities that were attributed to an arachnoid cyst or benign brain cyst. However, the remaining inquiry is whether the evidence demonstrates the incurrence of an arachnoid cyst in service or as a result of service. Upon review of the evidence, the Board concludes that the evidence of record is against a finding that the Veteran’s arachnoid cyst is related to his military service. The Veteran endorsed “no” for tumor, growth, cyst, or cancer on his September 1990 separation examination report of medical history. At separation for his final period of service in February 2006, the Veteran endorsed “yes” for the same conditions. A November 2011 brain MRI showed a 2 x 1.0 cm arachnoid cyst adjacent to the Veteran’s right temporal lobe. The reviewing clinician described the cyst as “likely incidental.” VA examined the Veteran in September 2013. The Veteran’s 2011 arachnoid cyst diagnosis was noted. The Veteran reported that he fell in 1987 and sustained a neck strain. He reported a 1988 incident involving heat trauma with short changes in consciousness, a 1992 fall resulting in left knee and right-side injuries, and chemical exposure. The examiner also noted the Veteran’s 2004 surgery to excise facial cancer and his 2007 pituitary tumor diagnosis. The examiner rendered the clinical assessment that the Veteran’s central nervous arachnoid cyst (2.2 x 1.0) adjacent to the right temporal lobe is likely incidental and was less likely as not incurred in or caused by the inservice injury, event, or illness. A May 2015 VA treatment note indicates that the Veteran had a 2.5 cm benign brain cyst. An April 2016 VA treatment note shows that the brain cyst is on the left temporal area, close to the Veteran’s eye. The examiner noted that a neurosurgeon did not want to perform surgery on the cyst and endorsed it as an “incidental cyst.” During the August 2016 Board hearing, the Veteran testified that a handrail hit him in the head while he was driving a Coast Guard boat and that he reported the incident to the chief corpsman. He testified that a subsequent in-service fall could have aggravated the head injury. The Veteran also testified that he injured his head when he fell down a three-story hill, and hit his head on a “2x6.” The Veteran testified that he was exposed to toluene that could have caused the cyst. According to the Veteran, a private surgeon informed him that the blow to his head “set a lot of things in motion.” A review of the medical evidence indicates that the Veteran continued treatment for the arachnoid cyst through March 2018. The Veteran reported 2 mini strokes with incidental arachnoid cyst since his previous medical visit to the VA pain management clinic in January 2018. Upon review of the foregoing evidence, the Board finds that service connection for arachnoid cyst (clamed as cyst temporal lobe) is not warranted. The clinical evidence indicates that the Veteran has a current diagnosis of arachnoid cyst. STRs do not indicate that the Veteran complained of, was treated for, or was diagnosed with an arachnoid cyst during service. The Veteran, however, only reported having a medical history of a tumor, growth, cyst, or cancer on his February 2006 separation examination. When considered as a whole, the medical evidence does not establish a nexus/relationship between the Veteran’s arachnoid cyst and his service. A November 2011 brain MRI showed an arachnoid cyst on the Veteran’s right temporal lobe; however, it was described as “likely incidental.” The September 2013 VA examiner rendered the clinical assessment that the arachnoid cyst is likely incidental and was less likely as not incurred in or caused by inservice injury, event or illness. Again, on VA outpatient treatment in April 2016, the examiner noted that a neurosurgeon declined to perform surgery on the cyst and endorsed that it is an “incidental cyst.” It is well established that a medical opinion “must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.” See Stefl, supra. The probative value of a medical opinion is generally based on the scope of the examination or review, as well as the relative merits of the expert’s qualifications and analytical findings, and the probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion. See Sklar, supra. As in the present appeal, the September 2013 VA examiner reviewed the evidence of record, conducted an in-person examination, and provided a persuasive basis for his medical opinion. Most crucially, the clinician’s impression of the November 2011 MRI and the April 2016 VA examiner’s assessment are consistent with the September 2013 medical opinion that the arachnoid cyst is likely incidental and not attributable to the Veteran’s service. The Board notes that a neurological surgeon examined the Veteran during the course of his appeal and attributed the Veteran’s cervical sympathetic nerve injury and global brain atrophy to service, but did not attribute his arachnoid cyst to his active duty service. With regards to the Veteran’s assertions, lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but are not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). The Veteran contends that he injured his head and was exposed to toluene in service and that his condition is related to his service. However, the Veteran does not possess the medical expertise or specialized knowledge to provide a probative opinion regarding the nexus/relationship between his arachnoid cyst and military service. For the foregoing reasons, the Board finds that service connection for arachnoid cyst (claimed as cyst temporal lobe) must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, supra. 5. Entitlement to service connection for a hernia, to include an umbilical hernia repair The Veteran contends that his hernia, to include umbilical hernia repair, is related to his military service. A review of the clinical evidence indicates that the Veteran does not have a currently diagnosed hernia. These clinical records note that the Veteran had an abdominal hernia repair in 1996, prior to active duty. The records also note the Veteran’s well healed umbilical repair. Specifically, STRs indicate that the Veteran endorsed “no” on the September 1990 separation examination report of medical history for rupture/hernia. A July 2001 physical examination report shows that the Veteran had an abdominal hernia repair in 1996, he has a well healed umbilical hernia scar, and he endorsed “yes” for rupture/hernia. On the February 2006 separation examination report the Veteran endorsed an abnormal abdomen and viscera, described as left lower quadrant tenderness to palpation. The Veteran’s 1996 abdominal hernia repair and umbilical surgical scar were noted. The Veteran did not have a hernia at separation from service. The question for the Board is whether the evidence demonstrates the incurrence of a hernia, including an umbilical hernia repair, in service or as a result of service. Upon review of the evidence, the Board concludes that the evidence of record is against a finding that the Veteran’s hernia, to include umbilical hernia repair, is related to his military service. VA examined the Veteran in September 2013. The Veteran was diagnosed with gastroesophageal reflux disease (GERD); epigastric distress; pyrosis (heartburn); reflux; and sleep disturbance caused by esophageal reflux. In October 2013, the RO sought a medical opinion, as the September 2013 examiner did not provide a medical opinion because he did not have the Veteran’s dates of service. In an October 2013 medical opinion, the VA examiner opined that there is no objective evidence that the Veteran has a current hernia. The examiner explained that the STRs reflect a 1996 umbilical hernia repair that occurred prior to active duty. A 2001 STR noted the Veteran’s “well healed umbilical hernia repair.” The Veteran’s umbilical hernia repair was noted in a 2006 medical record. Another 2006 medical record specifically noted that the Veteran exhibited no evidence of a hernia. During the August 2016 hearing, the Veteran testified that he had an umbilical hernia repaired in 1996. A review of the clinical evidence of record shows that the Veteran’s 1996 umbilical hernia repair is well documented. However, there is no clinical evidence of a current hernia. Based upon the evidence of record, the Board finds that service connection for a hernia, to include an umbilical hernia repair, is not warranted. The Veteran does not have a currently diagnosed hernia. The clinical evidence indicates that the Veteran’s 1996 umbilical repair/scar is well healed. There is no evidence of complaints, treatment, or diagnosis of a hernia or hernia repair during active duty. The clinical evidence, including STRs, consistently document the Veteran’s 1996 hernia and well healed umbilical hernia repair. Most notably, the October 2013 VA medical opinion indicates that there is no objective evidence that the Veteran has a current hernia and emphasized the fact that the Veteran has a well healed umbilical hernia repair. It is well established that a medical opinion “must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.” See Stefl, supra. The probative value of a medical opinion is generally based on the scope of the examination or review, as well as the relative merits of the expert’s qualifications and analytical findings, and the probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion. See Sklar, supra. As in the present appeal, the October 2013 VA examiner reviewed the evidence of record, conducted an in-person examination, and provided a persuasive basis for his medical opinion. The opinion is afforded significant probative value as it speaks to the question at hand, whether the Veteran has a current disability and if that disability was incurred in, or caused by his service. With regards to the Veteran’s assertions, lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but are not competent to establish that which would require specialized knowledge or training, such as medical expertise. See Layno, supra. The Veteran contends that he had an umbilical hernia repaired in 1996. However, the Veteran does not possess the medical expertise or specialized knowledge to provide a probative opinion regarding the diagnosis of an abdominal and/or umbilical hernia and the nexus/relationship between his hernia, including the well-healed umbilical repair, and military service. For the foregoing reasons, the Board finds that service connection for a hernia, to include an umbilical hernia repair must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, supra. REASONS FOR REMAND 1. Entitlement to service connection for deviated septum (claimed as septal deviation surgery), to include residuals of septoplasty is remanded The Veteran’s October 1985 enlistment examination report indicates that he had mild childhood asthma until age 11. The Veteran reported that the asthma resolved and that he has not had any asthma related problems or has taken any medication for asthma since childhood. STRs indicate that the Veteran complained of difficulty breathing as early as February 1986. A December 1986 STR indicates that the Veteran was diagnosed with an upper respiratory infection (URI). The examiner noted that the Veteran did not sound congested. The Veteran was diagnosed with an URI in June 1988 and his turbinates were red without drainage. His sinuses were tender to palpation without evidence of adenopathy. The Veteran was diagnosed with allergic rhinitis in May 1989 and probable bronchitis, secondary to viral URI, in August 1989. His history of sinus congestion was noted. At separation in September 1990 and February 2006, the Veteran endorsed “yes” for hay fever, asthma, or any other breathing problem. He endorsed “no” for ear, nose, or throat trouble. The July 2001 physical examination report of medical history reflects that the Veteran endorsed “yes” for ear, nose, or throat trouble; hay fever; and asthma. Past minor, ear, nose and throat infections were noted. An outpatient treatment record in October 2003 noted that the Veteran was diagnosed with snoring with presumed obstructive sleep apnea, obstructive nasal septum deviation, and turbinate hypertrophy. The Veteran reported chronic nasal obstruction on the left side. Examination of the nose with fiberoptic scope revealed moderate to moderately severe elements of left nasal obstruction with compensatory hypertrophy of the right inferior turbinate. The Veteran was scheduled for septoplasty and turbinate reduction to maximize his nasal airway. VA referred the Veteran to the otorhinolaryngology clinic. The October 2003 private ear, nose, and throat (ENT) report noted the Veteran’s chronic nasal obstruction with septal deviation and inferior turbinate hypertrophy and recommended a: septoplasty, inferior turbinate submucous resection (SMR), a polysomnogram (sleep study), and continuous positive airway pressure (CPAP) trial. The private physician noted that the Veteran smoked at least two packs of cigarettes per day. After a February 2004 private overnight sleep study, the Veteran was diagnosed with primary snoring. Weight reduction, oral appliance, and Somnoplasty were recommended. A November 2004 VA treatment note indicates that the Veteran was diagnosed with chronic rhinitis and surgery was required. The examiner noted that a second opinion by an ENT specialist was needed to determine if surgery was necessary or if a CPAP and other treatments would suffice. The Veteran underwent a septoplasty in March 2005. He presented with a deviated septum and fragments of nasal bone and cartilage were unremarkable. A follow-up examination, post-septoplasty, shows that the Veteran was “doing well.” The physician discussed the risks of smoking, but the Veteran declined a formal smoking cessation referral. A July 2012 computed tomography (CT) scan showed that the Veteran had mild high right nasal septal deviation, moderate to severe bilateral inferior turbinate hypertrophy, large left middle turbinate concha bullosa, and mild inflammation involving the left maxillary and ethmoid sinuses bilaterally. Frontal and sphenoid sinuses showed no evidence of sinusitis or polypoid disease. The Veteran underwent corrective septum surgery in August 2012. VA examined the Veteran in September 2013. The Veteran was diagnosed with non-allergic rhinitis and his deviated septum diagnosis was noted. The Veteran’s history of mild hay fever was also noted. The Veteran reported that his trouble breathing through his nose began in the military. The Veteran was never diagnosed with a broken nose prior to service. The Veteran’s March 2003 and August 2012 septoplasties were noted. The VA examiner rendered the clinical assessment that the Veteran’s sinus condition is most likely caused by or a result of septoplasty. During the August 2016 hearing, the Veteran testified that his deviated septum was repaired during service. He testified that his nasal breathing problems began during active duty. The Veteran attributed his in-service congestion to being aboard a “40-year old ship,” inhaling mold, and hitting his head. The Veteran testified that on several occasions, he hit his nose and had a nose bleed. The Board finds that a medical opinion is required to determine the nature and etiology of the Veteran’s deviated septum and diagnosed sinus condition. The Veteran has reported breathing problems since enlistment in service. The Veteran was diagnosed with allergic rhinitis, probable bronchitis, and had his deviated septum repaired during active duty. Since separation, the Veteran has undergone corrective septum surgery and was diagnosed with non-allergic rhinitis and left maxillary, ethmoid, and sphenoid sinus mucosal disease. A September 2013 VA examiner attributes the Veteran’s currently diagnosed sinus condition to septoplasty. As such, the Board finds that a medical opinion is required to clarify the etiology of the Veteran’s deviated septum and related sinus conditions. The Board notes that although service connection cannot be granted for defects of congenital, developmental, or familial origin, such a defect can still be subject to superimposed disease or injury. VAOPGCPREC 82-90. If such superimposed disease or injury does occur during service, service connection may be warranted for the resulting disability. Id. Moreover, pursuant to O’Bryan v. McDonald, 771 F.3d 1376 (Fed. Cir. 2014), a congenital or developmental condition that is progressive in nature-that can worsen over time-is considered a disease rather than a defect. Thus, the Board finds that the nature and etiology of the Veteran’s deviated septum (claimed as septal deviation surgery), to include residuals of septoplasty is unclear and an additional opinion is necessary. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from the September 2013 VA physician, or if not available, a qualified medical professional to determine the nature and etiology of the Veteran’s deviated septum and sinus condition. The examiner is asked to thoroughly review the electronic claims file, as well as a copy of this Remand. Specifically, the examiner is asked to provide an opinion that addresses the following questions: (a) Is the Veteran’s deviated septum a congenital disease or congenital defect? For purposes of VA compensation, a congenital “defect” is defined as a condition that is more or less stationary in nature, whereas a congenital “disease” is defined as a condition capable of improving or deteriorating. (b) If it is determined that the Veteran’s deviated septum is a congenital defect, is it at least as likely as not (a 50 percent or greater probability) that the Veteran suffers from additional disability, namely a sinus condition (allergic/non-allergic rhinitis, chronic rhinitis, left maxillary, ethmoid, and sphenoid sinus mucosal disease, chronic nasal obstruction, and inferior turbinate hypertrophy) due to aggravation of the defect during service (from November 1985 to November 1990 September 2001 to October 2001, and/or February 2003 to April 2006) because of a superimposed disease or injury? (c) If it is determined that the Veteran’s deviated septum is a congenital defect, is it at least as likely as not (a 50 percent or greater probability) that the Veteran suffers from additional disability, namely a sinus condition (allergic/non-allergic rhinitis, chronic rhinitis, left maxillary, ethmoid, and sphenoid sinus mucosal disease, chronic nasal obstruction, and inferior turbinate hypertrophy) due to the March 2003 septoplasty? (d) If it is determined that the Veteran’s deviated septum is a congenital disease, is it clear and unmistakable that the Veteran entered service (from November 1985 to November 1990 September 2001 to October 2001, and/or February 2003 to April 2006) with a pre-existing deviated septum? If YES, is it clear and unmistakable that the Veteran’s pre-existing deviated septum WAS NOT aggravated beyond the natural progress of the disorder during his service? (Continued on the next page)   In so opining, the examiner is requested to specifically address the Veteran’s history of mild childhood asthma until age 11 and the fact that he has not taken medication for asthma since it resolved. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Taylor, Associate Counsel