Citation Nr: 21015611 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 16-12 316 DATE: March 17, 2021 REMANDED Entitlement to service connection for a condition claimed as vertigo and dizziness, to include peripheral vestibular disorder, and/or benign paroxysmal positional vertigo, and/or Meniere’s disease, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1954 to January 1975. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) denying service connection for vertigo and dizziness. In November 2020, the Board remanded the claim for an addendum opinion regarding an ambiguity in a prior VA etiology opinion. Though the directed addendum opinion was provided in December 2020, the Board regrettably finds that an additional remand is required in order to cure an inadequacy with the new opinion. The December 2020 clinician returned a negative opinion regarding a relation between the Veteran’s current condition and an in-service streptomycin injection, remarking that “[b]esides the dizziness, tinnitus, and vertigo which occurred right after the streptomycin injection, the record is silent with regards to a chronic condition with these symptoms,” and that “[t]he record does not mention, as far as I saw, any medical evaluations for dizziness or vertigo save for the 1967 streptomycin injection.” As noted by the Veteran’s representative in a March 2021 informal hearing presentation, the December 2020 opinion appears to have disregarded the competent statements from the Veteran regarding additional episodes of vertigo and dizziness months after the injection, which are described both by the Veteran’s own testimony and by in-service letters to his wife relating dizziness and nausea while riding in the back of a truck. The fact that there is not an objective medical record of these episodes may not serve as the sole basis for a negative medical opinion, and objective medical evidence or absence thereof may not strictly be preferred over competent lay evidence. Dalton v. Nicholson, 21 Vet. App. 23, 39, 40 (2007). The Board notes that though the December 2020 clinician is the same clinician who authored the earlier August 2020 opinion that did expressly consider the Veteran’s in-service letters to his wife, in the August 2020 opinion the examiner addressed those letters with an ambiguous suggestion that the Veteran’s dizziness while riding in the trucks was due to a “condition [which] would predispose [him] to that symptom.” In the new December 2020 addendum, the clinician clarified that there is no evidence to support that the Veteran had a predisposing condition; however, the clinician did not reconsider and address the Veteran’s letters as pieces of evidence relating to continuing episodes of vertigo and dizziness while still in service. Finally, the Veteran’s representative also argued in the March 2021 informal hearing presentation that the VA clinician’s quotation of an UpToDate entry in the August 2020 opinion did not provide citations to the supporting sources referred to in the quote or provide the full text of those supporting sources, depriving the Veteran and his representative of the ability to review and respond to the negative evidence underlying the clinician’s opinion. The Veteran and his representative request that the footnoted articles be made available for their comment and review, so the Board will direct for that information to be supplied on remand. Accordingly, the matter is REMANDED for the following action: (This appeal has been advanced on the docket. Expedited handling is requested.) 1. Obtain an addendum opinion regarding the etiology of the Veteran’s vertigo and dizziness. If possible, obtain the opinion from the author of the December 2020 addendum opinion. (a) The clinician is asked to answer whether it is at least as likely as not that the in-service injection of streptomycin is related to any present condition manifesting in the Veteran’s vertigo and dizziness, specifically including but not limited to benign paroxysmal positional vertigo (diagnosed at a September 2019 VA examination), and/or peripheral vestibular disorder (diagnosed at an August 2020 VA examination), and/or Meniere’s disease (related by the Veteran at the February 2019 Board hearing that his doctor, as well as mentioned in the December 2020 VA opinion), and/or acute viral labyrinthitis (referred to in a May 2000 private treatment note (uploaded into the virtual record 5/20/2013)). In rendering this opinion, the clinician MUST consider and discuss both (i) the Veteran’s reports, as corroborated by in-service letters to his wife, that in the months after receiving the injection which caused the episode of dizziness, nausea, and ear-ringing, he again experienced episodes of dizziness and nausea when riding in the back of trucks traveling on windy mountain roads; and (ii) the Veteran’s statement that before the streptomycin shot he never had the symptoms of vertigo, dizziness, and nausea, and that “the vertigo attacks [he] ha[s] experienced after the streptomycin shots are identical to the one [he] had the day of the shot.” An opinion that only remarks that there is no formal medical evidence of in-service vertigo and dizziness beyond the date of the streptomycin injection will be inadequate. (b) Additionally, the clinician must provide citations to the sources quoted in the August 2020 VA opinion’s quote of an UpToDate article (that is, the paragraph in the rationale beginning “Aminoglycosides are associated with….”; please provide citations to the UpToDate article quoted and to the sources “[70]” and “[71]”). Alternatively, the clinician may provide the entire text of the UpToDate article cited and its footnotes. 2. After the above development and any other development deemed necessary is completed, readjudicate the Veteran’s claim. K. Parakkal Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Davis, 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.