Citation Nr: 21075461
Decision Date: 12/20/21	Archive Date: 12/20/21

DOCKET NO. 17-55 289
 DATE: December 20, 2021

REMANDED

Entitlement to service connection for a recurrent vestibular disability, including vertigo, is remanded.   

REASONS AND BASES FOR REMAND

The Veteran had active service from December 1963 to November 1966.   

Entitlement to service connection for a recurrent vestibular disability, including vertigo, is remanded.  

The Veteran asserts that service connection for a recurrent disability manifested by vertigo is warranted as the claimed disability was manifested secondary to the service connected mastoidectomy residuals.  

Service connection may also be granted for disability which is proximately due to or the result of a service connected disease or injury.  38 C.F.R. § 3.310(a).  Service connection shall be granted on a secondary basis under the provisions of 38 C.F.R. § 3.310(a) where it is demonstrated that a service connected disorder has aggravated a nonservice connected disability.  Allen v. Brown, 7 Vet. App. 439 (1995).  Service connection has been established for mastoidectomy residuals with bilateral hearing loss and tinnitus.  

Department of Veterans Affairs (VA) clinical documentation dated in May 2001 states that the Veteran was diagnosed with oyogenic vertigo and "likely inner ear disturbance with paroxysmal vertigo." 

The report of a November 2019 ear examination conducted for VA states that the Veteran was diagnosed with mastoiditis "review of records shows no evidence of any vertigo related diagnoses in the service treatment records and no evidence of any post service other than what is noted in the DBQ examinations."  The examiner concluded "based on this evidence, it is less likely than not that there is a current vertigo condition related to service."  Given the physician assistant's failure to note or to otherwise address the diagnoses of oyogenic vertigo and possible inner ear disturbance with paroxysmal vertigo, the Board finds that the examination report is of essentially no probative value. 

VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive.  McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991).  When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate.  Barr v. Nicholson, 21 Vet. App. 303, 312 (2007).  The Board finds that further VA evaluation is needed.  

The matter is REMANDED for the following action:

Schedule the Veteran for a VA examination conducted by a medical doctor to assist in determining the current nature and severity of the claimed recurrent vertigo disability.  The examiner must review the record and should note that review in the report.  A rationale for all opinions should be provided.  The examiner should:

(a.) Diagnose all vestibular disabilities.  If recurrent vertigo is not identified, the examiner must specifically state that fact.  

(b.) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified recurrent vestibular disability had its onset during active service or is related to any incident of service.  

(c.) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified recurrent vestibular disability is due to or the result of the mastoidectomy residuals and the other service connected disabilities. 

(d.) Opine whether it at least as likely as not (50 percent probability or greater) that any identified recurrent vestibular disability has been aggravated (increased in severity beyond the natural progression of the disorder) by the mastoidectomy residuals and the other service connected disabilities.  

 

 

J. T. HUTCHESON

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Emily A. Kotroco

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.