Citation Nr: 18137167 Decision Date: 09/20/18 Archive Date: 09/20/18 DOCKET NO. 15-37 642 DATE: September 20, 2018 REMANDED Entitlement to service connection for vertigo and sensation of fullness of the ears is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1968 to August 1970. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a December 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office in Cleveland, Ohio. The Veteran testified at a personal hearing before the Board in May 2017, and a transcript of the hearing is of record. See Transcript. Entitlement to service connection for vertigo and sensation of fullness of the ears is remanded. The Veteran contends that he is entitled to service connection for vertigo and sensation of fullness of the ears. Unfortunately, this matter must be remanded for a new VA examination. In May 2017, the Veteran testified at a personal hearing before the Board that, during a period of service, he incurred a head injury, and, as a result, the Veteran manifested vertigo and fullness in his ears thereafter. See Transcript. The Veteran underwent a VA examination in July 2010. The examiner indicated that the Veteran reported intermittent symptoms of fullness and vertigo, but the examiner did not provide a diagnosis based on these symptoms. In an August 2010 addendum to the July 2010 examination, the examiner indicated that the Veteran’s claims file did not contain documentation of vertigo, and that the examiner’s opinion had not changed. Additionally, the Veteran was previously diagnosed with and granted service connection for hearing loss and tinnitus. The Veteran has provided competent lay evidence of head trauma during a period of service as well as competent evidence of vertigo and tinnitus. This is sufficient to trigger VA’s duty to assist, because this could suggest that the Veteran is manifesting the residuals of a traumatic brain injury characterized by vertigo. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran was provided a VA examination, but the examination did not evaluate this possibility. As such, this matter must be remanded for another VA examination to discuss this possibility. Barr v. Nicholson, 21 Vet. App. 303 (2007). Additionally, the constellation of symptoms (hearing loss, tinnitus, vertigo, and fullness of the ears) potentially suggests Meniere’s disease. See MedlinePlus “Meniere’s disease” available at https://medlineplus.gov/menieresdisease.html. VA’s duty to assist requires VA to seek a medical opinion on whether or not a diagnosis of Meniere’s disease is appropriate when the Veteran has provided competent reports of dizziness, sensory hearing loss, and tinnitus. Connolly v. Derwinski, 1 Vet. App. 566 (1991). As such, the examiner should discuss whether or not the Veteran has a diagnosis of Meniere’s disease and, if so, the etiology thereof. The matter is REMANDED for the following action: 1. Copies of pertinent updated treatment records, VA and non-VA, should be obtained and added to the claims file. 2. Following completion of the above, arrange to provide the Veteran with a VA examination in order to address the following questions: (a.) Does the Veteran have a current diagnosis of Meniere’s disease; why or why not; and, if so, when did it first begin to manifest? (b.) What is the medical significance, if any, of the fact that the Veteran has reported vertigo, hearing loss, tinnitus, and fullness in the ears? Why? (c.) If the Veteran does have a diagnosis of Meniere’s disease, then is it at least as likely as not (50 percent or greater probability) that a medical nexus exists between an in-service incurrence and a current diagnosis of Meniere’s disease? Why or why not? (d.) Is the Veteran currently manifesting the residuals of a traumatic brain injury? Why or why not? (e.) What is the medical significance, if any, of the fact that the Veteran has provided credible evidence of a head injury in-service during a firearms mishap and that he manifested vertigo thereafter? Why? (f.) Does the Veteran have a diagnosis of vertigo? Why or why not? If not, what is the difference between the Veteran’s reports of experiencing vertigo, which the Board finds credible, and the medical criteria for a diagnosis of vertigo? (g.) Is it at least as likely as not (50 percent or greater probability) that a medical nexus exists between a current diagnosis of the Veteran’s claimed vertigo and fullness of the ears and an in-service incurrence to include a blow to the head during a firearms mishap. Why or why not? BARBARA B. COPELAND Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD David R. Seaton, Associate Counsel