Citation Nr: 21002026 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 16-21 009 DATE: January 12, 2021 ORDER Prior to April 12, 2016, a rating higher than 30 percent for chronic sinusitis is denied. From April 12, 2016, a rating of 50 percent for chronic sinusitis is granted. FINDINGS OF FACT 1. Prior to April 12, 2016, the Veteran’s sinusitis was manifest by more than six non-incapacitating episodes per year characterized by headaches, pain, and purulent discharge or crusting. 2. From April 12, 2016, the Veteran’s sinusitis is manifest by near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and crusting after repeated surgeries. CONCLUSIONS OF LAW 1. Prior to April 12, 2016, the criteria for a rating higher than 30 percent for chronic sinusitis are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.97, Diagnostic Code (DC) 6513. 2. From April 12, 2016, the criteria for a 50 percent for chronic sinusitis are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.97, DC 6513. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably on active duty in the United States Navy from February 1998 to August 2011. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In November 2019, the Board remanded this matter for further development. In June 2019, the Veteran testified in support of this appeal during a hearing held at the Seattle, Washington RO before the undersigned Veterans Law Judge. Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. The Veteran contends that he is entitled to a higher rating for his service-connected sinusitis. For the following reasons the Board finds that effective April 12, 2016, a 50 percent rating is warranted. The Veteran’s sinusitis is currently rated at 30 percent disabling under DC 6513. 38 C.F.R. § 4.97. Under DC 6513, a 30 percent evaluation is warranted when there are three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 50 percent rating is warranted for sinusitis following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. A note provides that an incapacitating episode of sinusitis means one that requires bed rest and treatment by a physician. The Veteran submitted a July 2016 sinusitis disability benefits questionnaire. His symptoms are listed as chronic sinusitis detected only by imaging studies, headaches, pain of affected sinus, tenderness of affected sinus, purulent discharge, and crusting. It is also noted that the Veteran had undergone seven endoscopic surgeries to remove polyps, with his most recent surgery being in 2016. VA treatment records indicate that he had surgery in June 2016. In January 2019, the Veteran underwent a VA examination. His symptoms were noted to be episodes of sinusitis, headaches, pain of affected sinus, and purulent discharge. It is also noted that the Veteran missed fourteen days of work the previous year due to his sinusitis. VA treatment records document the extent of the Veteran’s sinusitis. In July 2014, the Veteran reported that he continues to have sinus issues of drainage and pressure with headaches. In a March 2016 review of systems checklists, the Veteran has reported sinus problems with stuffiness and discharge. A May 2016 primary care note includes an assessment of a recent CT scan of the Veteran’s sinuses that showed diffuse polypoid sinus mucosal thickening resulting in complete opacification of the bilateral frontal sinuses and left sphenoid sinus, and occlusion of the bilateral sphenoethmoidal recesses. Surgery was then scheduled for June 2016. A June 2016 otolaryngology consult reviewed the Veteran’s April 2016 CT scan and assessed him with recurrent Sinonasal polyposis. The consult note also states that the Veteran previously underwent endoscopic surgery for his sinusitis in 1998, 1999, 2001, 2002, 2009, and 2010. In a July 2016 otolaryngology note the Veteran is evaluated after his June 2016 surgery and found to have a nasal crust/scab in his left nasal cavity that was removed. His mucosa was pink and moist, and it was found that irrigation was triggering surgical site bleeding. The Veteran also reported lightheadedness, nausea, vomiting, headaches, and nosebleeds lasting ten minutes. In a September 2016 review of systems, the Veteran continued to report nosebleeds along with itching of the nose. The Veteran was seen by otolaryngology again in March 2017. He reported he was doing well since his June 2016 surgery, but a month ago started to experience sore throat, congestion, purulent discharge, and forehead pressure. Crusting and purulence was noted on examination and the Veteran was assessed with a sinus infection. In a March 2017 primary care review of systems, the Veteran again reported stuffiness and discharge. This is repeated in October 2017. The next report from the Veteran on his sinusitis is from January 2019 where he reported sinusitis without significant improvement from medication prescribed by a non-VA provider. It was noted that the Veteran had tenderness and purulent discharge. Private treatment records for the Veteran’s sinusitis have been obtained. In October 2014, the Veteran rated his symptoms a five out of ten and reported primarily facial pain/pressure. On examination polyps were noted with a large polyp seen in the right maxillary and polypoid tissue obstructing the frontal recess. The assessment states that the Veteran would likely require an additional endoscopic polypectomy. In July 2019, the Veteran underwent his eighth sinus surgery. He was recommended the surgery in June 2019. Prior to surgery, the Veteran had polyps beyond middle meatus, thick and purulent discharge, mild scarring/adhesions, and mild crusting. It was recommended he have endoscopic sinus surgery due to failure of Veteran having long term improvement. During surgery, a large crust was removed from the left maxillary sinus and polyps were grade 2/4 bilateral frontal and ethmoid sinuses that were completely obstructing the frontal recess. After surgery the Veteran reported doing alright, but had a headache he rated a three out of ten in severity. The Veteran had some blood-tinged drainage that was decreasing in frequency and quantity. Discharge was still thick and purulent and scarring/adhesions was mild. His edema had improved to mild. The Veteran though did have severe crusting after his surgery. In November 2014, the Veteran submitted a statement reporting that he continued to experience nosebleeds, pressure, headaches, and discharge several times a year. At his June 2019 hearing, the Veteran testified that he had missed five weeks of work that year due to his sinusitis. The Board finds that from April 12, 2016, the date of his CT scan that led to his seventh sinus surgery, the Veteran is entitled to a 50 percent rating for his chronic sinusitis. The Veteran has consistently reported the symptoms provided for a 50 percent rating and has had eight endoscopic sinus surgeries to alleviate his symptoms. The Board cannot award a higher rating prior to April 12, 2016. Though the Veteran was reporting the symptoms of headaches and pain there was no evidence of purulent discharge or crusting until the CT scan that suggested additional surgery was needed. Without evidence of crusting or purulent discharge and the need for additional surgery, the Board cannot award a 50 percent rating earlier than the date assigned. According, the Board finds that from April 12, 2016, a 50 percent rating is warranted for the Veteran’s chronic sinusitis. JOHN Z. JONES Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Michael Chandeck, Associate Counsel 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.