Citation Nr: 21076795 Decision Date: 12/27/21 Archive Date: 12/27/21 DOCKET NO. 14-41 496A DATE: December 27, 2021 ORDER Entitlement to service connection for vertigo is denied. FINDING OF FACT The preponderance of the evidence weighs against a finding that the Veteran's vertigo was incurred during or as a result of service or is secondary to a service-connected disability. CONCLUSION OF LAW The criteria for service connection for vertigo have not been met. 38 U.S.C. § 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1970 to August 1977. This appeal arises from a January 2015 rating decision which, in pertinent part, denied entitlement to service connection for vertigo. During the pendency of the appeal, the Veteran provided testimony regarding his vertigo claim before Veterans Law Judge (VLJ) White in April 2019 and VLJ Donohue in August 2020. Transcripts of both hearings are of record. Since two VLJs have received testimony in relation to the vertigo claim, the Veteran is entitled to a panel decision and another hearing with the third member of the panel before the claim is adjudicated. Arneson v. Shinseki, 24 Vet. App. 379 (2011). During the August 2020 hearing, the Veteran waived his right to a hearing before the third member of the panel. This claim has been remanded by the Board on three previous occasions, including most recently in August 2021, to ensure the Veteran has been provided an adequate VA opinion. The claim is once again before the Board for further consideration. 1. Entitlement to service connection for vertigo Generally, service connection may be established if the evidence demonstrates that a disability resulted from a disease or injury incurred in or aggravated by active duty service. 38 C.F.R. § 3.303. In that regard, service connection may be established for any disease diagnosed after discharge, when all the evidence, including that pertinent to the period of service, establishes the disease was incurred during active duty service. 38 C.F.R. § 3.303(d). In order to establish service connection, there must be competent and credible evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus, or link, between the current disability and the in-service disease or injury. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Veteran asserts that his vertigo is related to his period of active service or, in the alternative, is secondary to his service-connected bilateral hearing loss and/or tinnitus disabilities. As for direct service connection, the Veteran's service treatment records (STRs) show that he sought treatment for dizziness and lightheadedness on a few occasions during service. In July 1970, the Veteran reported feeling dizzy, weak, and lightheaded for two days, for which he was prescribed bed rest. The following day, clinicians noted the Veteran returned for treatment of hyperventilation and passing out, for which they prescribed salt tablets and water. In July 1972, the Veteran complained of headaches, coughing, vertigo, and general malaise, at which time he also presented with a high temperature. In January 1973, the Veteran presented with a lump on his head that reportedly caused headaches and dizziness. In May 1974, he, again, reported experiencing dizziness frequently, nervousness, and vertigo in the morning and with motion. After clinical evaluation, he was diagnosed with serous otitis in the left ear. The STRs do not contain any subsequent complaints or treatment for vertigo, dizziness, or other related symptoms after 1974, but the foregoing evidence confirms that the Veteran manifested symptoms indicative of and similar to vertigo during service. Indeed, the Veteran has asserted that he first noticed balance difficulties during service, including tripping and falling sometimes and slipping off an aircraft. See e.g., April 2019 hearing transcript, p.7; and August 2020 hearing transcript, p.6. The Veteran has also asserted that his symptoms, including dizziness and nausea, worsened after service and have continued since service to include episodes during which the room spins, he loses his balance, and he feels disoriented. See April 2019 hearing transcript, p.10; August 2020 hearing transcript, p.10; and December 2014 VA ear conditions examination. The first post-service evidence of vertigo is shown in January 2001, at which time the Veteran endorsed experiencing dizziness, decreased hearing, and headaches. He reported that his first episode of dizziness and vertigo occurred in December 2000 while he was walking and looked down, but he stated that his most recent episode occurred that same month and, otherwise, described his dizziness and vertigo as intermittent and precipitated by position changes. One week later, the Veteran reported he was feeling better and that his symptoms resolved spontaneously. Nevertheless, after examination and balance testing, the Veteran was diagnosed with benign paroxysmal positional vertigo (BPPV). See also January 2001 VA treatment record. Subsequent VA treatment records dated in 2002 and 2004 show the Veteran denied experiencing any reoccurrence of his vertigo episodes but, in 2019, he endorsed having an acute occurrence of vertigo with feelings of dizziness and nausea. See e.g., VA treatment records dated June 2002, March 2004; private treatment records dated January and October 2019; see also April 2013 VA treatment record. While the foregoing evidence reflects symptoms of or similar to vertigo during and after service, which would satisfy the first and second elements of service connection, the Board finds the preponderance of the evidence does not reflect that the current vertigo disability, i.e., BPPV, was likely incurred during or as a result of his period of active service or is secondary to his service-connected bilateral hearing loss or tinnitus disabilities. In other words, the third element of service connection, the nexus, has not been established. As noted in the Introduction, this claim has been remanded on more than one occasion to obtain an adequate medical opinion that addresses the likelihood that the Veteran's current vertigo disability is directly related to service or is secondary to a service-connected disability based upon consideration of the lay and medical evidence of record. In August 2021, a VA physician reviewed the claims file and opined that it is less likely than not that the claimed vertigo disability was incurred in or caused by an in-service injury, event, or illness. As an initial matter, the VA physician noted the Veteran's report of dizziness and vertigo on active duty but further noted that vertigo is a symptom and, in this regard, stated that the actual etiology producing the symptom is an important consideration. The VA physician noted the various symptoms documented in the STRs. With respect to the symptoms of lightheadedness and dizziness reported in July 1970, the physician stated that, to the general population, lightheadedness and vertigo are often described as dizziness but are completely different medically, as lightheadedness usually points to a circulatory problems (such as dehydration), whereas vertigo suggests an inner ear or brain problem. As for the vertigo and other symptoms reported in July 1972, the physician noted the combination of symptoms suggests the Veteran had a viral syndrome and further noted that the vertigo manifested at that time would be viral induced, as such as by ear infection, labyrinthitis, or vestibular neuronitis. Similarly, the physician noted that the vertigo and other symptoms documented in May 1974 were diagnosed as serous otitis, which he stated suggests the examiner felt was due to fluid buildup in the ear from congestion or infection. In this regard, the VA examiner noted that infections causing vertigo are similar to having an upper respiratory infection (URI) or cold and can recur but that each episode is considered acute and self-limiting, not a chronic condition. In this context, the VA physician who provided the August 2021 opinion noted the Veteran's current diagnosis of BPPV, which he stated was first noted in January 2001 and diagnosed by medical experts that specialize in vertigo who also noted that the Veteran's first episode was in December 2000, more than 20 years after service. The VA physician acknowledged that the Veteran recalls having dizziness on active duty and attributes his dizziness to what he started having in 2001, which was diagnosed as vertigo; however, the physician stated that "dizziness" and "vertigo" are symptoms and opined that, based on the STRs, are unrelated to the current chronic condition of vertigo due to BPPV. Given this finding, the Board does not find that the Veteran's disability has continued since service. The opinion provided by the August 2021 VA physician with respect to direct service connection is considered competent, credible, and probative evidence of record, as the physician provided a rationale in support of the opinion which is based on consideration of the relevant lay and medical evidence and is consistent with the other evidence of record. Indeed, the VA physician distinguished the symptoms of dizziness and vertigo reflected in the STRs from the vertigo due to BPPV shown and diagnosed after service, primarily on the basis that the in-service symptoms were shown to be acute in nature and generally due to viral or other conditions. In this regard, the Board finds probative that the August 2021 VA physician addressed the Veteran's lay statements regarding the onset of symptoms during service but was able to provide a medical explanation as to why the in-service symptoms are unrelated to the current chronic disability. The Board also finds probative that the basis and medical foundation of the August 2021 VA opinion is echoed in other medical opinions of record which, while previously deemed inadequate for various reasons, consistently suggests that, in general, vertigo is a symptom and, as specific to this case, is shown to be an acute symptom manifested with other symptoms during service that is distinguishable from the BPPV diagnosed after service. See e.g., VA opinions dated December 2014 and March 2021. For example, in December 2014, a VA physician noted that vertigo can be a symptom of dehydration and infection, as reflected in the Veteran's STRs, whereas BPPV is due to malfunction in the vestibular apparatus which can occasionally be caused by direct trauma to the apparatus but is often associated with natural age-related degeneration of the otolithic membrane in older people. In March 2021, a VA clinician opined that it is less likely than not that the claimed vertigo disability is proximately due to, a result of, or underwent any incremental increase in disability by his service-connected hearing loss or tinnitus. In this regard, the clinician noted that the medical literature does not support that vertigo can be caused or aggravated by hearing loss or tinnitus. Instead, the clinician noted that the medical literature indicates that BPPV is a common form of vertigo attributed to calcium debris within the posterior semicircular canal without any indication of a pathophysiologic mechanism for hearing loss or tinnitus to cause or aggravate BPPV beyond normal progression. In support of this claim, the Veteran's representative has identified a blog post from a hearing clinic for the proposition that "tinnitus and vertigo are very closely related." See June 2021 representative statement. Although medical treatise evidence can be sufficient to establish a nexus in some cases, the Board finds that this blog post is not a medical treatise. The article is unsigned, does not reference any medical studies, and encourages the reader to get a hearing test from the clinic's office. To the extent the website provides medical information, the blog post states that "tinnitus is not a disease but rather a symptom resulting from problems with the auditory system (or another underlying medical condition.)" It similarly reports that vertigo is not a disease but a symptom that can be the result of a variety of issues. The article then concludes that because tinnitus and vertigo are both symptoms that can involve ear problems, they are commonly associated with one another and are closely related. The website cited by the Veteran's representative is too general in nature to establish service connection. The article does not specifically relate to the facts and circumstances surrounding the Veteran's particular medical history or the etiology of his vertigo, BPPV. This citation is not the equivalent of a statement from a medical expert who reviewed the Veteran's medical history and/or examined the Veteran and rendered an opinion based on the specifics of the Veteran's history. In this capacity, the Board observes that the VA physician who provided the December 2014 medical opinion noted that, while the vestibular organ is housed in the inner ear, the vesicular organ does not subserve hearing functions in the outer or middle ear or vice versa. It was noted that there is no scientific evidence that the source of the Veteran's vertigo (BPPV) is caused by or a result of tinnitus. Therefore, the Board finds that the VA opinions provided in December 2014 and March 2021, when combined, are the most competent, credible, and probative evidence of record with respect to whether the current vertigo disability is secondary to the service-connected hearing loss or tinnitus disabilities. Indeed, as noted, the opinions are supported by complete rationale and are consistent with the other lay and medical evidence of record which does not show or suggest that the Veteran's BPPV is caused by or manifested by any incremental increase in severity due to his hearing loss or tinnitus. In evaluating the ultimate merit of this claim, the Board finds probative there is no medical evidence or opinion of record that suggests or indicates that the Veteran's current vertigo disability, BPVV, was incurred during service, is otherwise related to service, or is caused or aggravated by a service-connected disability. The Board acknowledges the Veteran's belief that his current vertigo disability began during service and is secondary to his service-connected hearing loss or tinnitus. While the Veteran is competent to report experiencing vertigo, the evidence of record indicates that vertigo can have multiple causes and the Veteran is not competent to provide an opinion on the etiology of his symptoms. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Essentially, there has been no continuity of symptomatology, where the evidence does not reflect, nor has the Veteran alleged, that he has any medical education, experience, or training. Nor has he offered any basis in common lay knowledge to support his opinion. Therefore, the Veteran's statements and beliefs in this regard are not considered more persuasive than the medical opinions of record. To the extent the Veteran contends that he has had vertigo ever since his in-service complaints, the Board finds such statements not credible. As discussed, the first post-service evidence of vertigo comes from a January 2001 treatment records wherein the Veteran described that his symptoms began a month ago. This statement directly contradicts any allegation of ongoing symptoms. Cf. White v. Illinois, 502 U.S. 346, 356, 112 S.Ct. 736 (1992) (holding that a statement made in the course of procuring medical services, where the declarant knows that a false statement may cause misdiagnosis or mistreatment, carries special guarantees of credibility). Based on the foregoing, the Board finds the preponderance of the evidence is against a finding that the Veteran's current vertigo disability, i.e., BPPV, was incurred during or as a result of his military service or is secondary to a service-connected disability. As such, service connection for vertigo is denied and the benefit-of-the-doubt doctrine is not applicable. M. Donohue Veterans Law Judge Board of Veterans' Appeals YVETTE R. WHITE Veterans Law Judge Board of Veterans' Appeals P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Turnipseed, 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.