Citation Nr: 21013617 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 09-23 443A DATE: March 10, 2021 ORDER Entitlement to service connection for obstructive sleep apnea (OSA), claimed as a respiratory disorder is granted. FINDING OF FACT The Veteran’s OSA is aggravated secondary to service-connected sino-bronchial syndrome. CONCLUSION OF LAW The criteria for entitlement to service connection for OSA, claimed as a respiratory disorder, as secondary to service-connected sino-bronchial syndrome have been met. 38 U.S.C. § 1110; 38 C.F.R. § 3.310.   REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1963 to August 1967. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO or AOJ), denying service connection for a respiratory disorder. The Veteran’s claim initially came before the Board in March 2014. The Veteran’s claim was recharacterized to include all respiratory disorders other than sino-bronchial syndrome and was remanded for additional development to include obtaining a VA medical opinion. The matter was most recently remanded in January 2020 due to the inadequacy of the VA medical opinions in the record. Entitlement to Service Connection for OSA The Veteran contends that service connection is warranted for OSA as it was caused by his service-connected sino-bronchial syndrome. See March 2020 statement. Generally, to establish service connection, the evidence must show (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 current disability and the in-service disease or injury. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Service connection may also be established for any disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998).   The first and second requirements for service connection have been met. The Veteran was initially diagnosed with OSA in January 2002 in a private sleep study. The diagnosis of OSA was confirmed at a September 2006 VAMC sleep study. The Veteran is also service-connected for sino-bronchial syndrome. What remains for consideration is whether there is a nexus between the Veteran’s diagnosed OSA and the service-connected sino-bronchial syndrome. After review of the evidence, the Board finds that service connection is warranted for OSA as it is secondary to service-connected sino-bronchial syndrome. A September 2016 VA medical opinion in support of the claim concluded that the Veteran’s OSA is at least as likely as not related to military service. Reference was made to the diagnosis of sino-bronchial syndrome, which included sinusitis, bronchitis, and asthma, and a PFT that showed combination of restrictive and obstructive ventilator defect and he was later diagnosed with OSA in 2000. The examiner stated that sinusitis can cause nasal congestion which can lead to swelling and inflammation of the upper airway passages resulting in snoring and sleep apnea. Following the Board’s latest remand, an August 2020 VA medical opinion was obtained to address the September 2016 findings. The examiner stated that the Veteran had undergone corrective nasal and sinus surgery in 2001, and that the subsequent records indicated the Veteran’s nose and sinus function was good, his nasal passages were normal sized with clear nasal passages, and there was no airflow obstruction. The examiner, therefore, concluded that nasal congestion was not a factor in the Veteran developing OSA. In a September 2020 addendum opinion, the examiner remarked that the Veteran had also asserted that his sleep apnea is due to Agent Orange. The examiner stated there is no medical evidence Agent Orange leads to or aggravates sleep apnea. As there was also no evidence the Veteran had sleep apnea while in the service, the examiner also concluded that it was less likely than not incurred in during service. The August 2020 examiner, however, did not address evidence supportive of the Veteran’s claim which includes a February 2020 private treatment record from the Veteran’s treating physician. Dr. M.W. indicated the Veteran’s records showed that he “clearly has had for a number of years allergies, nasal congestion, chronic bronchitis, mucus hypersecretion which have contributed to upper airway pharyngeal obstruction which is aggravating his clinical condition of OSA.” Dr. M.W. also indicated the Veteran has been unable to tolerate wearing a CPAP device, full facemask, or additional pillow type makes due to his service connected respiratory disorder. Such is supported by the Veteran’s treatment records. A June 2009 treatment record documents the Veteran report that he was unable to use the CPAP in the past, as it causes asthma. A January 2011 treatment record showed chronic, uncontrolled post nasal drip and nasal drainage likely due to intolerance and, therefore, decreased use of nasal steroid. Treatment records from September 2012 to April 2013 document complaints of on and off cough and congestion. In May 2013, the Veteran wrote that his asthma and COPD had worsened and was not controlled consistently with medications and treatment. He stated that he had constant coughing and exacerbations that disrupted his sleep and daily routine. The Board finds that the evidence of record is at least in equipoise regarding a nexus between the Veteran’s OSA and the service-connected sino-bronchial syndrome. While Dr. M.W.’s February 2020 opinion lacks clear rationale, it is based on his consistent treatment of the Veteran, review of treatment records, and personal knowledge of the Veteran’s condition. On the other hand, the August 2020 VA opinion seems to be based on a lack of documentation of nasal congestion in the Veteran’s treatment. However, such disregards the Veteran’s consistent reports of failure to respond to extensive medical therapy for sino-bronchial trouble, wheezing, nasal obstruction, snoring, cough, and trouble breathing. See December 2004 treatment record. A March 2007 VA treatment record further noted the Veteran’s goal was to be able to sleep at night and that he is currently restricted from doing so because of post nasal drainage that chokes him causing coughing. A May 2009 treatment record documents a failed dental appliance trial, and diagnosis of moderate degree of obstructive sleep hypopnea and mild to moderate snoring. A January 2020 treatment record indicates the Veteran sought urgent care due to coughing and post-nasal drip.   The record also contains May 2014, October 2018, June 2019, and November 2019 VA opinions against the claim. However, the evidence is at least in equipoise and will resolve all doubt in favor of the Veteran. The Board finds that service connection is warranted for OSA as secondary to the service-connected sino-bronchial syndrome. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Smith, 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.