Citation Nr: 21064557 Decision Date: 10/20/21 Archive Date: 10/20/21 DOCKET NO. 14-31 794A DATE: October 20, 2021 ORDER Service connection for obstructive sleep apnea (OSA) is denied. FINDING OF FACT It is less likely than not that the Veteran's OSA was either incurred in or caused by his active military service, to include any exposure to chemicals, or is secondary to either his service-connected PTSD or his service-connected migraine headaches. CONCLUSION OF LAW The criteria for service connection for OSA have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.310(a). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Navy from July 1989 to April 1997. The matter is on appeal before the Board from a November 2013 rating decision. The Veteran and his spouse provided testimony at a Board hearing in November 2017 before the undersigned Veterans Law Judge. A transcript of the hearing is of record. The Board previously remanded the issue for further development in April 2018 and June 2021. Service Connection OSA The Veteran asserts that his sleep apnea is related to his active military service. Specifically, in his Notice of Disagreement (NOD) submitted in December 2013, his Form 9 Appeal to the Board submitted in November 2016, and at his November 2017 Board hearing, the Veteran testified that he was exposed to chemicals during his active service, which he believes resulted in his current diagnosis of OSA. In addition, the Veteran's spouse testified at the November 2017 Board hearing that the Veteran snored and stopped breathing during his sleep. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disability which is aggravated by a service-connected disability. In order to prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509 (1998). A review of the Veteran's service treatment records (STRs) does not show a diagnosis for OSA, nor do they show any complaints or treatments that may be related to OSA. A review of the Veteran's VA treatment records reflects that the Veteran was seen for a neurology consultation in January 2010. During the consultation the Veteran reported that he does not sleep well. His wife said he snores. He relayed that he began having trouble with sleeping four years prior, and that he felt that it was associated with being turned down for employment. He reported that he had been snoring for three years. A sleep study was ordered. The Veteran underwent a sleep study in February 2010. It was noted that the sleep study was being performed due to complaints of frequent snoring. The Veteran was diagnosed with OSA that was at least moderate in severity. The Veteran underwent a VA examination in July 2019, at which the examiner opined that it was less likely than not (less than 50 percent probability) that the Veteran's OSA was incurred in or caused by his active military service. The examiner explained that although the Veteran does have a diagnosed OSA condition, there is no evidence found in medical literature of OSA incurred in or caused by the Veteran's active service. While there are studies that show a prevalence in TBI/concussion patients, OSA is an anatomical abnormality. According to medical literature from the American Lung Association, OSA occurs when the back of the throat (the pharynx) collapses while you are sleeping. The pharynx relies on muscles to stay open, but these muscles relax when you sleep. When the muscles relax, the pharynx collapses, which slows or stops air from entering and exiting your lungs. To unblock the pharynx, you wake briefly to "flex" the pharynx muscles and start breathing again. This cycle happens over and over throughout the night, and often you don't even realize it is happening. Therefore, the examiner found that a nexus had not been established for direct service connection. The examiner also opined that it was less likely than not (less than 50 percent probability) that the Veteran's OSA was proximately due to or the result of the Veteran's service-connected PTSD. The examiner explained that the two conditions are not medically related. The claimed disorder, sleep apnea, is an entirely separate and unrelated entity from the Veteran's service-connected PTSD with residuals of head injury. Medical literature shows that there is an increased risk of those with PTSD to have OSA, but it does not show that PTSD can cause OSA. There is no mental condition that causes OSA. OSA is a disease with a clear and specific etiology. It is a common disorder that is characterized by the narrowing or collapse of the pharyngeal airway during sleep. It is caused by anatomical variations in the craniofacial features and/or neck. There is no evidence to suggest it is due to PTSD or any other mental condition. The examiner finished the opinion by providing citations to medical literature. In addition, the examiner opined that it was less likely than not (less than 50 percent probability) that the Veteran's OSA was proximately due to or the result of the Veteran's service-connected headaches. The examiner explained that the two conditions are not medically related. The claimed disorder, sleep apnea, is an entirely separate and unrelated entity from the Veteran's service-connected migraine headaches. The medical literature does not support a medical relationship. The examiner reiterated that sleep apnea is a common disorder characterized by the narrowing or collapse of the pharyngeal airway during sleep. It is caused by anatomical variations in the craniofacial features and/or neck. Migraine headaches do not cause anatomical variations of the craniofacial features and/or neck. Therefore, the examiner found that a nexus had not been established between the Veteran's OSA and his service-connected migraine headaches. An additional VA medical opinion was obtained in July 2021. After review of the Veteran's record and a phone interview with the Veteran in July 2021, the VA examiner opined that it was less likely than not (less than 50 percent probability) that the Veteran's OSA began in or was otherwise caused by his active military service, to include any exposure to chemicals. The examiner explained that chemicals cannot obstruct the upper airways and lead to sleep apnea. The examiner noted that they appreciated the statements presented in the Veteran's file from the Veteran and his wife. The examiner quoted the Veteran's spouse stating: "My husband is severely depressed and has been having manic episodes. He is also not sleeping. He is up all night. When he does doze off, he has been having nightmares or recurrent dreams of when he got hit in the head by a rotating antenna while onboard a Navy vessel." The examiner confirmed that the Veteran has both poor sleep hygiene and sleep apnea. His sleep issues are not obstructing his upper airways. Thus, the examiner found that a nexus was not present between the Veteran's OSA and his active military service, to include any exposure to chemicals. Based upon the foregoing, service connection for OSA is not warranted. The Veteran's STRs do not contain a diagnosis for sleep apnea, nor do they contain any complaints or treatments that may be related to OSA. The July 2019 and July 2021 VA medical opinions that have been provided are thorough and rationalized opinions, which provide probative value. The VA examiners found that it is less likely than not that the Veteran's OSA is either related to his active military service, to include any exposure to chemicals, or secondary to either his service-connected PTSD or migraine headaches. In addition, there are no objective medical findings of record that link the Veteran's OSA to either his active military service or to one of his service-connected disabilities. (Continued on the next page) Consideration is given to both the Veteran's and his spouse's contentions that the Veteran's claimed condition of sleep apnea was incurred in or caused by his military service, as well as the contention that his OSA is secondary to either his service-connected PTSD or migraine headaches. While lay persons are competent to provide opinions pertaining to certain medical issues, the etiology of OSA, as is specific to this case, is outside the realm of common knowledge for someone, such as either the Veteran or his spouse, who does not possess medical training, specialized expertise, or experience. Jandreau v. Nicholson, 492. F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Veteran and his spouse are competent to report the Veteran's symptoms of snoring as well as that he stops breathing while sleeping, however, no probative value shall be assigned to either the Veteran's or his spouse's statements pertaining to the etiology of his sleep apnea, as the etiology of sleep apnea is a medically complex issue. As such, the weight of the evidence is against a finding that service connection for OSA is warranted. Therefore, service connection for OSA is denied. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Lutgens-Staley, 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.