Citation Nr: 19161358 Decision Date: 08/08/19 Archive Date: 08/07/19 DOCKET NO. 1438844 DATE: August 8, 2019 ORDER Entitlement to service connection for a right foot disability is dismissed. Service connection for bruxism is granted. Service connection for a right ankle disability, diagnosed to include degenerative joint disease (DJD), or arthritis, is granted. Service connection for a left shoulder disability, diagnosed to include acromioclavicular DJD and osteoarthritis, is granted. Service connection for a deviated septum is granted. REMANDED Entitlement to service connection for a bilateral ear disability, beyond that of hearing loss and tinnitus, claimed as bilateral otitis media, is remanded. Entitlement to service connection for right-ear hearing loss is remanded. Entitlement to service connection for an acquired psychiatric disorder, including, but not limited to unspecified depressive disorder, unspecified trauma and stressor related disorder, and unspecified neurocognitive disorder, claimed as posttraumatic stress disorder (PTSD), is remanded. Entitlement to an initial compensable rating for service-connected left-ear hearing loss is remanded. Entitlement to an initial compensable rating for service-connected status-post right styloid fracture, right wrist, is remanded. FINDINGS OF FACT 1. During the Veteran’s February 13, 2019, Board hearing, prior to the promulgation of a decision in the appeal, he requested withdrawal of the appeal of his claim of entitlement to service connection for a right foot disability. 2. The Veteran’s bruxism was incurred during active service. 3. The Veteran injured his right ankle during service, has experienced right ankle symptoms continuously since separation from service, and has been diagnosed with DJD, or arthritis, of the right ankle. 4. The Veteran injured his left shoulder during service, has experienced left shoulder symptoms continuously since separation from service, and has been diagnosed with acromioclavicular DJD and osteoarthritis of the left shoulder. 5. The Veteran’s deviated nasal septum was incurred during active service. CONCLUSIONS OF LAW 1. The criteria for withdrawal of a Substantive Appeal on the issue of entitlement to service connection for a right foot disability have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.204. 2. The criteria for service connection for bruxism have been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. § 3.303. 3. The criteria for service connection for a right ankle disability, diagnosed to include DJD, or arthritis, have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1133, 5107; 38 C.F.R. §§ 3.304, 3.307, 3.309. 4. The criteria for service connection for a left shoulder disability, diagnosed to include acromioclavicular DJD and osteoarthritis, have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1133, 5107; 38 C.F.R. §§ 3.304, 3.307, 3.309. 5. The criteria for service connection for a deviated nasal septum have been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1986 to April 2011. The Veteran and his spouse testified at a Travel Board hearing before the undersigned Veterans Law Judge (VLJ) on February 13, 2019. A copy of the transcript of that hearing is of record. Dismissal Entitlement to a service connection for a right foot disability. Under 38 U.S.C. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. Withdrawal of an appeal may be made by the appellant or by his authorized representative prior to the Board’s issuance of a final decision. 38 C.F.R. § 20.204. Until the appeal is transferred to the Board, a withdrawal of an appeal is effective when received by the agency of original jurisdiction. Thereafter, it is not effective until received by the Board. During the Veteran’s February 13, 2019, Board hearing, he stated that he was withdrawing his appeal of the claim of entitlement to service connection for a right foot disability. He explicitly, unambiguously, and with a full understanding of the consequences, withdrew his appeal of his claim. The undersigned clearly identified the withdrawn issue and the Veteran affirmed that he was requesting a withdrawal as to this appeal. See Acree v. O’Rourke, 891 F.3d 1009 (Fed. Cir. 2018). The Board therefore finds that the Veteran has withdrawn this appeal. The withdrawal was memorialized in the hearing transcript, prior to the issuance of a final decision on this matter. The withdrawal was thus made in the form and manner required by 38 C.F.R. § 20.204. The filing, then, effectively withdrew the relevant Notice of Disagreement and Substantive Appeal; accordingly, no allegation of error of fact or law remains before the Board for consideration with regard to this issue. The Board, therefore, does not have jurisdiction over the appeal of this claim, and the appeal must be dismissed. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d, 78 F.3d 604 (Fed. Cir. 1996). Alternatively, continuity of symptomatology may be established if a claimant can demonstrate: (1) that a condition was “noted” during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology under 38 C.F.R. § 3.303 (b); Barr v. Nicholson, 21 Vet. App. 303 (2007). Where a claimant asserts entitlement to a chronic condition but there is insufficient evidence of a diagnosis in service, he can establish service connection by demonstrating a continuity of symptomatology since service, but only if the chronic disease is listed under 38 C.F.R. § 3.309 (a), including arthritis. Walker v. Shinseki, 708 F.3d 1331, 1337-39 (Fed. Cir. 2013). Such chronic diseases are presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C. §§ 1110, 1112, 1131, 1133; 38 C.F.R. §§ 3.307, 3.309(a). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a claimant is competent to report on that of which he or she has personal knowledge). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has considered the Veteran’s claims and decided entitlement based on the evidence. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record, with respect to his claims. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 1. Entitlement to service connection for bruxism. The Veteran, during active service, in February 2008, presented for treatment for sleep apnea. He reported that he grinds his teeth at night and has a dental guard; he was diagnosed with bruxism. It is not clear the precise date upon which he was prescribed a dental guard for bruxism or the date upon which he was first diagnosed with bruxism; however, the Veteran’s January 1986 service entrance examination and history reports are silent for such. There is thus no indication that the Veteran’s bruxism was diagnosed prior to service; in essence, there is no indication that the Veteran was not diagnosed with bruxism during his active service. On VA examination in March 2011, conducted while the Veteran was still in active service, for the purpose of adjudicating his service connection claims, he reported the onset of his bruxism as two or three years prior and the examiner noted his in-service treatment with a dental device for grinding. The Veteran denied current treatment and reported that his bruxism had improved since its onset; he was diagnosed with bruxism. While the Department of Veterans Affairs (VA) Regional Office (RO), in its May 2012 rating decision that denied entitlement to service connection for bruxism, determined that there was no evidence of an event, disease, or injury during service, it does not appear that the RO considered the Veteran’s February 2008 in-service bruxism. The analysis may thus be stated simply, the Veteran has a current disability, bruxism, that was incurred in active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). The Board thus finds that service connection for bruxism is warranted. 2. Entitlement to service connection for a right ankle disability, diagnosed to include DJD, or arthritis. The Veteran, during service, in July 1993, presented with blunt trauma during a jump; X-ray of the right calcaneus was unremarkable. In June 1999, he complained of a right ankle injury while running; and by October 1999, such was diagnosed as an unresolved right ankle sprain and described as a slowly resolving right ankle sprain in December 1999. On VA examination in March 2011, the Veteran reported that his right ankle pain was worse than his left ankle pain; the examiner noted recurrent right ankle sprains documented in his service treatment records. Physical examination revealed that the Veteran had instability, pain, stiffness, and swelling, and recent X-ray examination was unremarkable. The examiner reported that there was no objective abnormality of the right ankle. However, VA treatment records dated in January 2014, reveal that the Veteran was diagnosed with DJD of the right ankle. During the Veteran’s February 2019 Board hearing, he asserted that his right ankle began “rolling out” during service and that he was still having problems with his right ankle. The Veteran is competent to report on-going right ankle symptoms, since separation from service, and there is no evidence that he is not credible in this regard. Layno, 6 Vet. App. 465, 470. Based on the forgoing, there is probative evidence of a current right ankle disability, diagnosed to include DJD, or arthritis, probative evidence of an in-service right ankle injury, and, resolving all doubt in favor of the Veteran, probative evidence of long-standing right ankle symptoms from the time of separation from service to the present. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1133; 38 C.F.R. § 3.309; Walker, 708 F.3d 1331, at 1337-39. The Board thus finds that service connection for service connection for a right ankle disability, diagnosed to include DJD, or arthritis, is warranted. 38 U.S.C. § 5107; Gilbert, 1 Vet. App. 49. 3. Entitlement to service connection for a left shoulder disability, diagnosed to include acromioclavicular DJD and osteoarthritis. The Veteran, during service, in September 1993, sought treatment for left shoulder trauma and was diagnosed with rotator tear versus tendinitis and/or bursitis. In October 1993, he was diagnosed with left shoulder bicipital tendinitis and/or impingement. On another occasion of treatment in October 1993, he was diagnosed with left shoulder strain. In December 1993, he was given a physical profile to refrain from certain physical activities for left shoulder impingement syndrome. In April 2000, he complained of bilateral shoulder pain, the treatment provider sought to rule out a rotator cuff tear versus supraspinatus tendinitis. In October 2010, he complained of bilateral shoulder pain. During VA treatment in March 2017, the Veteran was diagnosed by magnetic resonance imaging (MRI) with left shoulder degenerative acromioclavicular joint hypertrophy with additional degenerative changes. In April 2017, the VA treatment provider reported the Veteran’s chronic bilateral shoulder pain for many years, and noted that while March 2017 X-ray examination was unremarkable, the March 2017 MRI revealed acromioclavicular DJD. A May 2018 Disability Benefits Questionnaire (DBQ) reveals, in pertinent part, left shoulder acromioclavicular arthritis. In November 2018, during VA treatment, the Veteran was diagnosed with osteoarthritis of the bilateral shoulders. During his February 2019 Board hearing, the Veteran described his in-service left shoulder injuries and reported continuous symptoms since. The Veteran is competent to report on-going left shoulder symptoms, since separation from service, and there is no evidence that he is not credible in this regard. Layno, 6 Vet. App. 465, 470. Based on the forgoing, there is probative evidence of a current left shoulder disability, diagnosed to include acromioclavicular DJD and osteoarthritis, probative evidence of an in-service left shoulder injury, and, resolving all doubt in favor of the Veteran, probative evidence of long-standing left shoulder symptoms from the time of separation from service to the present. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1133; 38 C.F.R. § 3.309; Walker, 708 F.3d 1331, at 1337-39. The Board thus finds that service connection for service connection for a left shoulder disability, diagnosed to include acromioclavicular DJD and osteoarthritis, is warranted. 38 U.S.C. § 5107; Gilbert, 1 Vet. App. 49. 4. Entitlement to service connection for a deviated nasal septum. The Veteran, during active service, in March 2010, sought treatment for sleep apnea. The treatment provider reported that his nasal obstruction may be a contributing factor for such and diagnosed the Veteran with deviated nasal septum. It is not clear the precise date upon which he was diagnosed with a deviated nasal septum, however, the Veteran’s January 1986 service entrance examination and history reports are silent for such. There is thus no indication that the Veteran’s deviated nasal septum was diagnosed prior to service; in essence, there is no indication that the Veteran was not diagnosed with a deviated nasal septum during his active service. On VA examination in March 2011, conducted while the Veteran was still in active service, for the purpose of adjudicating his service connection claims, the Veteran reported the onset of a deviated nasal septum in 2010 and the examiner noted such in his service treatment records. Physical examination revealed no neoplasm, a history of nasal allergies, and no speech impairment; he was diagnosed with a deviated nasal septum. While the RO, in its May 2012 rating decision that denied entitlement to service connection for a deviated nasal septum, determined that there was no evidence of an event, disease, or injury during service, it does not appear that the RO considered the Veteran’s March 2010 in-service deviated nasal septum. The analysis may thus be stated simply, the Veteran has a current disability, a deviated nasal septum, that was incurred in active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). The Board thus finds that service connection for a deviated nasal septum is warranted. REASONS FOR REMAND 1. Entitlement to service connection for a bilateral ear disability, beyond that of hearing loss and tinnitus, claimed as bilateral otitis media. The Veteran, during service, sought treatment on a number of occasions for ear complaints. In November 1989, he complained of right-ear pain and was diagnosed with otitis externa. In November 1990, he underwent cerumen removal. In September 1991, he complained of left-ear pain and was diagnosed with cerumen impaction. In June 1992, he complained of right-ear pain second to a rupture of the tympanic membrane during diving. In July 1994, he presented with a history of recurrent otitis externa and was diagnosed with excessive cerumen buildup. In February 1998, he had cerumen obstruction. In November 2006, he complained of clogged, stuffed-up, muffled hearing, with a history of cerumen impactions, usually mechanically removed, and a prior history of multiple tympanic membrane perforations; he was diagnosed with otitis media and cerumen impaction. On VA examination in March 2011, the examiner considered the Veteran’s pertinent medical history, his in-service complaints, discussed above. The Veteran reported that there had been no recurrence for one or two years, that his ear condition had improved since its onset, and denied treatment, hospitalization, surgery, or trauma. On physical examination, there was no neoplasm, ear discharge, pruritus, balance or gait problems, ear infection, deformity of the auricle, abnormality of the external ear canal, or aural polyps; the tympanic membranes were normal, the mastoids were normal, and there was no complication of ear disease or secondary condition. There was no evidence of middle or inner ear infections, and the examiner noted that MRI in 2010 was unremarkable. The Veteran was diagnosed with bilateral otitis media, resolved. However, during his February 2019 Board hearing, the Veteran reported that he currently has ear infections about once a year, self-treated with medicine. The Veteran’s post-service VA treatment records appear silent for complaint, treatment, or diagnosis of bilateral otitis media. It is thus not clear if the Veteran has a disability related to his claim of entitlement to service connection for bilateral otitis media during the current appellate period. As his claimed bilateral otitis media was last examined by VA in March 2011, more than eight years prior, on remand, the RO should afford the Veteran a new VA examination to determine whether there exists a current ear disability, beyond that of hearing loss and tinnitus, claimed as bilateral otitis media, and if so, the etiology thereof. 2. Entitlement to service connection for right-ear hearing loss. The Veteran’s claim of entitlement to service connection for right-ear hearing loss was denied by the May 2012 rating decision on the basis that his March 2011 VA examination did not reveal right-ear hearing acuity comporting with the VA regulations to be considered a disability for compensation purposes under 38 C.F.R. § 3.385. During the Veteran’s February 2019 Board hearing, he asserted that the March 2011 VA examination was inadequate and that his right-ear hearing loss has worsened since. As such, on remand, the RO should afford the Veteran a new VA examination to determine the current severity of his right-ear hearing loss, and if such comports with the pertinent VA regulations, the etiology thereof, considering his in-service acoustic trauma associated with his proximity to the bombing that gave rise to his service-connected TBI as well as any other claimed in-service acoustic trauma or any in-service decrease in right-ear hearing acuity, and his numerous instances of bilateral ear pain with treatment for ruptured tympanic membranes, cerumen impaction, and otitis externa and media. 3. Entitlement to service connection for an acquired psychiatric disorder, including, but not limited to unspecified depressive disorder, unspecified trauma and stressor related disorder, and unspecified neurocognitive disorder, claimed as PTSD, is remanded. In December 2010, during service, PTSD appeared in the Veteran’s problem list in his service treatment records. The Veteran’s service separation document, his DD-214, indicates that he earned the Combat Infantryman Badge (CIB) and the Bronze Star with “V” device for valor and indicates that he served in numerous areas warranting imminent danger pay. On VA examination in March 2011, the examiner recited the Veteran’s pertinent medical history, noting a referral for assessment of PTSD during service in July 2010 at which time no rationale was provided for the referral. The examiner reported that the Veteran was also seen in October 2010, at which time he reported some traumatic events that he would like to document. During the March 2011examination, the Veteran reported that he was deployed over half of the time he was in service, and the most traumatic event he experienced was in 1998, when he was involved in recovery operations, post-explosion, of the terrorist bombing of the United States embassy in Nairobi. He reported that he saw dead and wounded coalition force personnel. The examiner reported that the Veteran’s reaction to such was not intense fear, feelings of hopelessness, feeling of horror, and that his reaction was anger. The Veteran reported that he did not seek treatment because he was busy with recovery efforts. He reported that he was inside the building that was bombed and lost consciousness, and that only nine of his fellow service members were able to walk away, that the room that they were in was the only room still intact. He reported some hyperarousal, depression and anxiety, and intrusive traumatic images for a few months after his deployment. He reported current insomnia and denied other psychiatric distress. He was diagnosed with insomnia. He denied depression and reported anxiety and restlessness. After exhaustive recitation of the diagnostic criteria required for a diagnosis of PTSD, the examiner determined that the Veteran did not meet such for PTSD. During VA treatment in March 2016, the Veteran was diagnosed with TBI, for which service-connected is in place, based on his loss of consciousness during the bombing, unspecified depressive disorder, and unspecified trauma and stressor related disorder. The treatment provider provided an exhaustive recitation of the diagnostic criteria required for a diagnosis of PTSD, the examiner determined that the Veteran did not meet such for PTSD. In March 2018, private treatment records indicate that the Veteran was being treated for PTSD. The private treatment provider reported that the Veteran sought treatment that month for PTSD related to his in-service stressors, and provided a narrative statement describing two requirements for a diagnosis of PTSD. The treatment provider did not specifically discuss the complete diagnostic criteria for a diagnosis of PTSD and report how the Veteran met such, and did not specifically attribute his PTSD to any specific in-service stressor. In January 2019, during VA treatment, the Veteran was diagnosed with unspecified neurocognitive disorder. The Board seeks additional medical comment on this issue. While the VA examiner, in March 2011, and the VA treatment provider, in March 2016, provided sufficient discussions of why the Veteran did not meet the diagnostic criteria for a diagnosis of PTSD, no party has discussed the propriety of the March 2018 private diagnosis of PTSD. No party has provided an opinion as to whether any acquired psychiatric disorder, including, but not limited to, unspecified depressive disorder, unspecified trauma and stressor related disorder, and unspecified neurocognitive disorder, is/are related to service, specifically, the Veteran’s in-service stressors. On remand, the RO should afford the Veteran a VA examination to address the Board’s inquires. 4. Entitlement to an initial compensable rating for service-connected left-ear hearing loss. The Veteran most recently underwent VA examination of his service-connected left-ear hearing loss in March 2011, more than eight years prior. During the Veteran’s February 2019 Board hearing , he asserted that the March 2011 VA examination was inadequate and that his disability has worsened since. As such, on remand, the RO should afford the Veteran a new VA examination to determine the current severity of his left-ear hearing loss. 5. Entitlement to an initial compensable rating for service-connected status-post right styloid fracture, right wrist. The Veteran most recently underwent VA examination of his service-connected status-post right styloid fracture, right wrist, in March 2011, more than eight years prior. During the Veteran’s February 2019 Board hearing, he asserted that his disability had not been examined by VA and that such had worsened over the years. As such, on remand, the RO should afford the Veteran a new VA examination to determine the current severity of his status-post right styloid fracture, right wrist. As to each of the issues remanded herein, the most recent VA treatment records available for Board review are dated in April 2019. On remand, the RO should obtain and associate with the claims file the Veteran’s updated VA treatment records. The matters are REMANDED for the following actions: 1. Obtain the Veteran’s VA treatment records for the period from April 2019 to the present. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected left-ear-hearing loss. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. To the extent possible, the examiner should identify any symptoms and functional impairments due to left-ear hearing loss alone and discuss the effect of such on any occupational functioning and activities of daily living. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected status-post right styloid fracture, right wrist. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to status-post right styloid fracture, right wrist alone and discuss the effect of such on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran’s statements. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any acquired psychiatric disorder, including, but not limited to, unspecified depressive disorder, unspecified trauma and stressor related disorder, and unspecified neurocognitive disorder, claimed as PTSD. (a) The examiner must specifically confirm whether a diagnosis of PTSD is warranted and discuss the propriety of the in-service December 2010 and post-service private March 2018 diagnoses of PTSD, each made without discussion of the appropriate diagnostic criteria. (b) The examiner must opine as to whether it is at least as likely as not that any acquired psychiatric disorder, including, but not limited to, unspecified depressive disorder, unspecified trauma and stressor related disorder, and unspecified neurocognitive disorder, and/or PTSD, if appropriate, is/are related to an in-service injury, event, or disease, including the Veteran’s in-service stressors, specifically, the stressor involving the bombing wherein he lost consciousness and participated in recovery efforts, to which his service-connected TBI is attributed, as well as any other claimed in-service stressors and in-service psychiatric complaints and treatment, considering that the Veteran earned the CIB and the Bronze Star with “V” device for valor and served in numerous areas warranting imminent danger pay. 5. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any right-ear hearing loss. For any right-ear hearing loss comporting with the VA regulations to be considered a disability for compensation purposes under 38 C.F.R. § 3.385, the examiner must opine as to whether it is at least as likely as not related to an in-service injury, event, or disease, including the Veteran’s in-service acoustic trauma associated with his proximity to the bombing that gave rise to his service-connected TBI as well as any other claimed in-service acoustic trauma or any in-service decrease in right-ear hearing acuity, and his numerous instances of bilateral ear pain with treatment for ruptured tympanic membranes, cerumen impaction, and otitis externa and media. 6. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any ear disability, beyond that of hearing loss, tinnitus, claimed as bilateral otitis media. (Continued on the next page) The examiner must opine as to whether it is at least as likely as not related to an in-service injury, event, or disease, including the Veteran’s in-service acoustic trauma associated with his proximity to the bombing that gave rise to his service-connected TBI as well as any other claimed in-service acoustic trauma or any in-service decrease in right-ear hearing acuity, and his numerous instances of bilateral ear pain with treatment for ruptured tympanic membranes, cerumen impaction, and otitis externa and media. P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Purdum The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.