Citation Nr: 20003835 Decision Date: 01/15/20 Archive Date: 01/15/20 DOCKET NO. 17-10 827 DATE: January 15, 2020 ORDER Entitlement to service connection for chronic rhinosinusitis claimed as sinus disease with polyps is granted. Entitlement to service connection for allergic rhinitis is granted. Entitlement to service connection for hypertension is granted. FINDINGS OF FACT 1. Resolving all reasonable doubt in favor of the Veteran, it is at least as likely as not that the Veteran’s chronic rhinosinusitis is etiologically related to service. 2. Resolving all reasonable doubt in favor of the Veteran, it is at least as likely as not that the Veteran’s allergic rhinitis is etiologically related to service. 3. Resolving all reasonable doubt in favor of the Veteran, it is at least as likely as not that the Veteran’s hypertension is etiologically related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for chronic rhinosinusitis are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303(a). 2. The criteria for service connection for allergic rhinitis are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303(a). 3. The criteria for entitlement to service connection for hypertension are met. 38 U.S.C. §§ 1110, 1112, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303(b), 3.307, 3.309(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty the United States Army from September 1999 to September 2004. The Veteran also had a verified period of active duty for training in the United States Army National Guard from June 1998 to August 1998, and active duty from February 2008 to March 2009, July 2011 to January 2012, and May 2013 to January 2014. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ) rating decision dated in December 2015. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may also 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). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1166-1167 (Fed. Cir. 2004). 1. Entitlement to service connection for chronic rhinosinusitis 2. Entitlement to service connection for allergic rhinitis In addition to the general service connection provisions set forth above, the Board notes that pertinent VA regulations provide that diseases of allergic etiology may not be disposed of routinely for compensation purposes as constitutional or developmental abnormalities. Service connection must be determined on the evidence as to existence prior to enlistment and, if so existent, a comparative study must be made of its severity at enlistment and subsequently. Increase in the degree of disability during service may not be disposed of routinely as natural progress or as due to the inherent nature of the disease. Seasonal and other acute allergic manifestations subsiding on the absence or removal of the allergen are generally to be regarded as acute diseases, healing without residuals. The determination as to service incurrence or aggravation must be on the whole evidentiary showing. 38 C.F.R. § 3.380. The Veteran seeks service connection for sinus disease and allergic rhinitis, which he asserts is related to service. At a May 2019 Board hearing, the Veteran testified that he began having severe sinus issues, which included drainage and trouble breathing, after he returned from Iraq in March 2009. The Veteran testified that he underwent sinus surgery in December 2010. He testified that the Army recalled him in June 2011 and he returned to Iraq. He testified that part of his duties during both tours in Iraq included going to incinerators and assuring that classified documents were properly destroyed or filed. The Veteran testified that when he returned from Iraq in January 2012, he continued to have sinus issues, and a private treatment provider diagnosed him with severe chronic rhinitis. He testified that he was deployed to Afghanistan in 2013, and when he returned, he underwent a balloon sinuplasty and later another functional endoscopic sinus surgery. The Veteran testified that following his sinus surgery, a VA treatment provider noted in his medical records that the amount of material removed from his nose was excessive, and he had membranes full of dirt. He testified that he continued to have issues and had to do sinus washes almost daily. In October 2012, a fellow service member reported that the Veteran had severe sinus issues and reported that they had been exposed to heavy dust conditions while clearing debris from blown up buildings in Iraq. In October 2012, the Veteran’s former spouse stated that following the Veteran’s return from service in Iraq in December 2011, he began having sinus problems and lost sleep due to headaches and breathing trouble. A July 1997 service treatment record reflects a diagnosis of pharyngitis and viral bronchitis. Physical examination revealed that his tonsils appeared to be swollen. A June 2004 service treatment record reflects diagnoses of sinusitis, bronchitis, pharyngitis, and allergies. Physical examination revealed that the Veteran had a lot of nasal congestion. A June 2004 service treatment record reflects that the Veteran’s chronic illnesses included seasonal allergies. March 2008 service treatment records reflect a diagnosis of upper respiratory infection. The treatment provider noted that the Veteran had nasal discharge and nasal passage blockage. A May 2009 Post-Deployment Health Assessment (PHDA) reflects that the Veteran had been deployed to Iraq from April 2008 to February 2009. The Veteran reported that he was exposed to sand/dust while he served in Iraq. A June 2010 VA examination indicated that the Veteran had two non-incapacitating episodes of sinusitis in the past 12-month period. In July 2010, a private treatment provider noted that the Veteran had been referred for evaluation of problems with nasal polyps, chronic sinus disease and problems with tinnitus. The treatment provider noted that the Veteran’s symptoms had been present on and off for the past 18 months. The Veteran’s symptoms included nasal obstruction, nasal drainage and sinus congestion. The Veteran reported that he had three infections in the past 12 months. He also reported having recurring sore throats and reported that he had been told that his tonsils were enlarged. Following examination including flexible fiber-optic examination of his nasopharynx, hypopharynx and larynx, the treatment provider opined that the Veteran’s symptoms were secondary to some combination of allergic rhinitis and chronic sinusitis. In September 2010 a private treatment provider noted that the Veteran returned for follow up regarding nasal obstruction. The treatment provider noted that the Veteran had a septal deviation to the left with moderately severe rhinitis and turbinate congestion. Allergy tests revealed that the Veteran had severe allergies to almost all items tested, including to both components of dust mite and many components of mold, as well as ragweed. The treatment provider opined that the Veteran’s nasal airway obstruction was multi-factorial in that there was a component from enlargement of tonsils and adenoids, he had a septal deviation, turbinate hypertrophy and a large amount of allergic rhinitis. The treatment provider noted that chronic sinusitis contributed to some extent as well. A June 2011 private treatment record reflects that the Veteran underwent an adenotonsillectomy. In February 2012, a private treatment provider noted that the Veteran had a diagnosis of perennial allergic rhinitis to mold with seasonal allergic rhinitis to pollens. The treatment provider noted that the Veteran had been having allergy symptoms, which consisted of severe nasal congestion, anterior rhinorrhea, postnasal drainage with sneezing episodes on a perennial basis for many years. The Veteran reported that he recently returned from Iraq in December and his symptoms drastically increased at that time. An April 2012 PHDA reflects that the Veteran had been deployed to Iraq for four months from August 2011 to December 2011. The Veteran reported that he had trouble breathing and bad headaches due to his deployment to Iraq. The Veteran reported that he was exposed to industrial pollution, sand/dust and smoke from burning trash or feces during his deployment. An April 2012 service treatment record reflects that the Veteran also reported that he began having shortness of breath in the middle of the night “hacking”. The Veteran reported that he was seeing a treatment provider for allergy shots three times a week, but the shots had not alleviated his shortness of breath. The treatment provider coded the Veteran’s treatment record as 987.9 - Toxic Effect of Unspecified Gas, Fume, or Vapor. An August 2012 VA treatment record reflects a diagnosis of allergic rhinitis and chronic rhinosinusitis. The treatment provider noted that the Veteran underwent a tonsillectomy and adenoidectomy, but they did not relieve his symptoms. The Veteran also did not improve greatly with weekly allergy shots over the last year. The Veteran was afforded a VA examination in November 2012, which reflected a diagnosis of allergic rhinitis from 2009 and chronic rhinosinusitis from 2009. The examiner noted that the Veteran came back from Iraq in 2009 and had allergy problems and had multiple ear, nose and throat (ENT) issues. The Veteran reported that he had a couple of sinus infections. He reported that on his last deployment he was around dust, which he thought made his allergies worse. The Veteran started taking allergy shots in 2009 after he returned from Iraq and stopped during his second deployment. He reported that when he returned, he had to increase the frequency of his shots. The examiner opined that the Veteran’s chronic rhinosinusitis and allergic rhinitis conditions were more likely as not (more than 50 percent probability) related to a specific exposure event during service in southwest Asia. The examiner opined that it would not be out of the realm of possibility for the Veteran to have problems with chronic rhinosinusitis and allergic rhinitis aggravated by the dusty environment where he and his fellow service member stated they worked. December 2012 VA treatment records reflect a diagnosis of chronic rhinosinusitis (CRS). The Veteran underwent a functional endoscopic sinus surgery (FESS) septoplasty. VA obtained an addendum opinion in July 2013 from the November 2012 VA examiner who opined that it was less likely than not (less than 50 percent probability) that the Veteran’s sinusitis and rhinitis were incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that the Veteran’s sinus problems were documented to have begun years before his last term of military service. The examiner noted that there was no medical evidence of record to support a contention that any term of service was cause of the sinus-related issues. The examiner further opined that the Veteran’s sinusitis and rhinitis which clearly and unmistakably existed prior to his last period of service and were aggravated beyond their natural progression by an in-service injury, event or illness. The examiner noted that the Veteran had polyps/retention cysts on facial CT prior to going to Iraq. The examiner noted that the Veteran had increased manifestations. Private treatment records reported an increase in the Veteran’s symptoms after returning from Iraq, and he had severe sinusitis on facial CT after returning from Iraq in 2011. The examiner noted that a private treatment provider reported that the Veteran’s sinus/allergy symptoms worsened after coming home from Iraq, and documentation revealed that the Veteran had worsening sinusitis on imaging after he got back, to the point that it was described as severe. A December 2014 VA treatment record reflects a diagnosis of chronic rhinosinusitis (CRS). The treatment provider noted that the Veteran had a several month/year histories of chronic sino-nasal pressure, congestion and drainage that was refractory to antibiotics, steroid nasal sprays and nasal saline irrigations so the Veteran underwent a functional endoscopic sinus surgery (FESS) septoplasty in December 2012. Since that time the Veteran was deployed to Iraq and was off all nasal sprays but had progressive worsening of his nasal congestion and had recently been treated with antibiotics without significant improvement. Since the Veteran’s last visit, he tried a nasal regimen, but he still had nasal congestion/obstruction and rhinorrhea. VA obtained an additional addendum opinion in November 2015. The examiner was asked to provide an opinion regarding whether the Veteran’s sinus disease with allergic rhinitis was at least as likely as not due to environmental hazards in Southwest Asia. The examiner opined that it was less likely than not (less than 50 percent probability) that the Veteran’s sinusitis and allergic rhinitis were incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that the Veteran’s sinus disease with allergic rhinitis (AR) clearly existed prior to service (EPTS). The examiner opined that the Veteran’s sinus disease and allergic rhinitis were most likely aggravated by living in the Ohio River Valley than any Southwest Asia exposure. The examiner noted that the Veteran currently had CT evidence of sinus disease, and further noted that sinus disease and allergic rhinitis were not Gulf War conditions. The November 2015 opinion that the Veteran’s sinus disease with allergic rhinitis clearly existed prior to service lacks probative value. The examiner did not discuss service treatment records of in-service respiratory issues including the July 1997 service treatment record which reflected a diagnosis of pharyngitis and bronchitis or the June 2004 service treatment record which reflected a diagnosis of sinusitis, and the examiner did not provide any rationale to support his opinion. Additionally, the examiner’s opinion that the Veteran’s sinus disease and allergic rhinitis were most likely aggravated by living in the Ohio River Valley than any Southwest Asia exposure also lacks probative value, as the examiner did not provide any rationale to support his opinion. Finally, the examiner’s opinion that it was less likely than not (less than 50 percent probability) that the Veteran’s sinusitis and allergic rhinitis were due to environmental hazards in Southwest Asia lacks probative value. The examiner did not address the Veteran’s statements that he had been exposed to pollution and sand and dust during his service in Iraq nor his competent and credible report of severe symptoms, and extensive and increased treatment following his deployments. The Board has carefully reviewed the evidence of record and finds that the criteria for direct service connection for chronic rhinosinusitis and allergic rhinitis have been met. The November 2012 VA examination establishes that the Veteran’s chronic rhinosinusitis and allergic rhinitis are related to service. The November 2012 VA examination is competent, credible and probative, and coupled with the other medical evidence of record including the July 2013 addendum opinion, the service records, VA treatment records, and lay evidence, supports a conclusion that the onset of such diseases was in service and that service connection for chronic rhinosinusitis and allergic rhinitis is warranted. See Guerrier v. Brown, 4 Vet. App. 467, 470-471 (1993); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Resolving all reasonable doubt in the Veteran’s favor, and with consideration of the objective medical evidence as well as the subjective lay evidence, the Board finds that the criteria for service connection for chronic rhinosinusitis and allergic rhinitis have been met. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to service connection for hypertension The Veteran seeks service connection for hypertension, which he asserts is related to service. At a May 2019 Board hearing, the Veteran testified that he began gaining weight, due to his service-connected back condition, which prevented him from engaging in hard physical training. The Veteran testified that he injured his back in June 2008 and when he went to Iraq, he began to gain weight because of his physical restriction and because of the food choices he had in Iraq. The Veteran testified that when he returned from Iraq, a service treatment provider noted that his blood pressure reading was a lot higher than it was prior to mobilizing to Iraq, and it was recommended that the Veteran have his blood pressure checked. The Veteran testified that after he returned from Iraq, he began receiving treatment and taking medication for high blood pressure. An August 1999 Report of Medical Examination reflects that the Veteran weighed 173 pounds and his blood pressure was 121/75 at enlistment. June 2004 service treatment records reflect that the Veteran weighed approximately 186 pounds and his blood pressure was 127/80; 189.5 pounds and his blood pressure was 134/82; 208 pounds and his blood pressure 123/79. In May 2009, the Veteran reported that he had chest pain or pressure that was related to his deployment to Iraq from April 2008 to February 2009. An October 2009 VA treatment record reflects a diagnosis of chronic low back pain, obesity, and degenerative disc disease of the lumbosacral (LS) spine. Physical examination revealed that the Veteran weighed 227.4 pounds and his blood pressure was 126/85. The Veteran was afforded a VA general examination in June 2010. The examiner noted that there was no evidence of congestive heart failure or pulmonary hypertension. Physical examination revealed that the Veteran’s blood pressure was 130/94, 128/90, and 128/90. The examiner noted that the Veteran had gained 68 pounds, which was 15 percent compared to baseline. A July 2010 private treatment provider noted that the Veteran’s blood pressure was slightly elevated at 130/99. A January 2012 private treatment record reflects a diagnosis of new onset hypertension. The Veteran reported that he had elevated blood pressure for the previous year. Physical examination revealed that the Veteran’s weight was 226 pounds and his blood pressure was 150/110. The treatment provider prescribed the Veteran medication for his hypertension. The Veteran was afforded a VA examination in November 2012, which reflected a diagnosis of hypertension from at least July 2012. The examiner noted that the Veteran reported that he had elevated blood pressure during medical processing when he returned from Iraq. The Veteran reported that he was sent to a private treatment provider who diagnosed him with hypertension and prescribed him medication. Physical examination revealed that his blood pressure was 150/104, 155/100 and 138/90. The examiner noted that the Veteran had his first two blood pressure readings taken while his bladder was very full, so the Veteran went to the restroom, after he returned his blood pressure improved. The examiner opined that the last of the three blood pressure readings was the most reflective of his normal blood pressure, since it was taken in his “normal” state after he relieved the discomfort of his bladder. The examiner opined that the Veteran’s hypertension condition was less likely as not (less than 50/50 probability) due to or the result of active service in the U.S. military. The examiner noted that there was competent evidence of a disease contracted, an injury suffered, or an event witnessed or experienced in active service. The examiner noted that there was not a showing a resulting chronic disability during service. The examiner noted that there was a showing of continuity of symptoms after service; the Veteran had elevated blood pressure and started on medication three days after separation from active duty. The examiner noted that it was higher than his previous elevations and he was started on medication for it. The examiner opined that there was competent evidence of a nexus or connection between the Veteran’s hypertension and his current disability. The examiner opined that from a medical standpoint, the Veteran’s hypertension was the result of gaining forty pounds since he ETS (expiration - term of service) from active service in 2004. The examiner opined that from the VA standpoint, it appeared that the Veteran had hypertension before going on active duty and there was aggravation while he was on active duty. The examiner noted that in actuality, it was unknown whether it was exacerbation or aggravation due to a dearth of information and treatment before exacerbation/aggravation could be determined. Nevertheless, the examiner opined that giving the Veteran the benefit of the doubt, he opined that the Veteran’s hypertension was aggravated due to his service. VA obtained an addendum opinion in July 2013 from the November 2012 VA examiner. The examiner opined that the Veteran’s hypertension was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that the Veteran had a current diagnosis of hypertension. The examiner noted that there was no evidence to support a contention of onset of hypertension during his last term of service and there was no evidence of continuity of symptoms; and therefore, there was no nexus. The examiner noted that the opinion had been changed because further review of the records did not provide enough support for the contention of hypertension caused or aggravated by active duty. The examiner did not provide an adequate rationale to support his July 2013 opinion that the Veteran’s hypertension was not aggravated by active duty. Notably, the examiner did not address his previous finding in November 2012 that the Veteran’s blood pressure was higher than his previous readings and he was started on medication for it three days after he returned from active duty in Iraq, which renders the examination inadequate. VA obtained an addendum opinion in November 2015. The examiner opined that the Veteran’s hypertension was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. The examiner noted that the Veteran had multiple periods of short-term activation. The examiner opined that it appeared that his hypertension was neither caused by nor aggravated by service. The examiner opined that the Veteran’s hypertension was due to genetics and morbid obesity. The examiner noted that the Veteran was diagnosed in between periods of activation and he currently had well controlled blood pressure on medication. Further, the examiner noted that hypertension was not a Gulf War condition. Although the November 2015 examiner noted that the Veteran was diagnosed in between periods of activation and was on medication; the examiner did not address the private treatment records which reflect that the Veteran was diagnosed with hypertension three days after he returned from service, which renders the examination inadequate. The Board has carefully reviewed the evidence of record and finds that the criteria for service connection for hypertension have been met. The November 2012 VA examination establishes that the Veteran’s hypertension is related to service. The November 2012 VA examination is competent, credible and probative, and coupled with the other medical evidence of record including the service records, VA treatment records, and lay evidence, supports a conclusion that service connection for hypertension is warranted. The Veteran separated from active duty service in January 2012. January 2012 private treatment records reflect that the Veteran’s blood pressure reading was 150/100; he was diagnosed with hypertension and he was prescribed medication for hypertension in January 2012. The Veteran competently and credibly testified that a service treatment provider noted that his blood pressure reading was a lot higher than it was prior to mobilizing to Iraq, and it was recommended that the Veteran have his blood pressure checked out, and subsequently sought treatment for high blood pressure when he returned from active duty service. Therefore, the Board finds that the Veteran’s testimony coupled with the private treatment records support a finding that hypertension manifested to a compensable degree within one year of separation of service. See Layno v. Brown, 6 Vet. App. 465, 469 (1994); 38 C.F.R. §§ 3.307, 3.309. Resolving all reasonable doubt in the Veteran’s favor, and with consideration of the objective medical evidence as well as the subjective lay evidence, the Board finds that the criteria for service connection for hypertension have been met. (Continued on the next page)   In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. Thus, resolving all reasonable doubt in favor of the Veteran and based on the medical and lay evidence of record, the Board finds that evidence of record supports a finding that service connection for hypertension is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert, supra. S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Johnson 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.