Citation Nr: 21064339 Decision Date: 10/19/21 Archive Date: 10/19/21 DOCKET NO. 17-42 895 DATE: October 19, 2021 REMANDED The claim of entitlement to service connection for a nasal condition is remanded. REASONS FOR REMAND The Veteran had honorable active duty service with the United States Army from January 1965 to January 1968. The instant matter is on appeal from a February 2017 rating decision. In July 2021, the Veteran testified before the undersigned in a virtual hearing. A transcript of the proceedings has been associated with the record. The Board notes that the Veteran has separately appealed claims of entitlement to an increased rating for an ankle disability and a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU). These claims have not yet been recertified to the Board following development. Accordingly, they will be addressed in a separate decision. 1. The claim of entitlement to service connection for a nasal condition is remanded. The Board regrets the additional delay, but remand is necessary to obtain an addendum medical opinion addressing the nature and etiology of the Veteran's claimed nasal condition. The Veteran reports that he was hit in the face with a metal bar during an in-service altercation, resulting in a broken nose. He experienced subsequent post-nasal drainage. In 1970, he reportedly underwent surgery for sinus polyps and had cartilage trimmed as a result of the broken nose. Since service, he reports experiencing a blocked nasal passage on the left side, and VA treatment records reflect reports of chronic nasal symptoms with some left nasal blockage. The Veteran's service treatment records reflect an altercation in May 1965 during which the Veteran hit his face against the bunk and lost consciousness. There was tenderness over his left maxillary and frontal bones. There was no indication of a break at that time. A July 1966 examination does not reflect ongoing complaints following this injury. In his February 1974 Reserve enlistment examination, the Veteran reported fracturing his skull and cheekbone in an August 1972 motorcycle accident. The August 2017 VA examination failed to diagnose a present disability. Computed tomography scan revealed that maxillary sinuses were "small, either due to development variation and/or prior trauma/surgery." The examiner was unable to confirm the reported in-service surgery based upon the record, and he noted that there was no present or historical diagnosis of a chronic nasal condition. The examiner explicitly stated that there was no documentation found in VA treatment records reflecting chronic nasal symptoms as far back as 2012. This is contradicted by more recent VA treatment records reflecting reports of chronic symptoms. Accordingly, an addendum medical opinion is necessary on remand to consider the reports of chronic sinus symptoms as reflected in VA treatment records. The matters are REMANDED for the following action: 1. Obtain any relevant, outstanding VA treatment records that are not already associated with the claims file. If no records are available, the claims folder must indicate this fact and the Veteran should be notified in accordance with 38 C.F.R. § 3.159(e). All attempts to contact the Veteran should be documented in the record. 2. Once the aforementioned development is complete, obtain an addendum medical opinion to address the nature and etiology of the Veteran's claimed nasal condition. A new examination may be scheduled if deemed necessary by the examiner. A complete copy of the claims file must be provided to the examiner, including a copy of this remand. The examiner should consider lay reports of observable symptomatology. After a thorough review of the record, the examiner should opine as to the following: (a.) List any and all present diagnoses pertaining to the nose or sinuses. Please specifically discuss the small passaged noted in the imaging study from the August 2017 examination. Please also discuss the specific sinus symptoms reported by the Veteran. (b.) For each identified diagnosis, is it at least as likely as not (i.e., a probability of 50 percent or more) that the disability had its onset during active service or within one year of separation from service, or, otherwise resulted from active military service? Please discuss the May 1965 injury, as well as the Veteran's contentions regarding a subsequent surgery. The examination report should specifically state that a review of the record was conducted. The examiner should provide a complete rationale for all opinions provided. If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. 3. Following completion of the foregoing, the AOJ should review the record and readjudicate the claim on appeal. If it remains denied, the AOJ should issue an appropriate supplemental SOC, afford the Veteran and his representative an opportunity to respond, and return the case to the Board. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H. Fisher, 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.