Citation Nr: 21020778 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 16-12 519A DATE: April 8, 2021 REMANDED Entitlement to service connection for a sinus disability, to include sinusitis, is remanded. Entitlement to service connection for a pulmonary disability, to include pulmonary fibrosis, is remanded. REASONS FOR REMAND The Veteran had active service from November 1966 to November 1969. The Veteran served in the Republic of Vietnam. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Fort Harrison, Montana. 1. Entitlement to service connection for a sinus disability, to include sinusitis, is remanded. 2. Entitlement to service connection for a pulmonary disability, to include pulmonary fibrosis, is remanded. The Veteran asserts that service connection for a sinus disability and a pulmonary disability are warranted as the disorders initially manifested during active service. The service medical records show that the Veteran underwent an ameliorating tonsillectomy in October 1967. In December 1967, he was hospitalized for a streptococcal infection. In a February 2016 VA examination, the Veteran noted a 2004 diagnosis of acute sinusitis. The Veteran reported that he developed rhinorrhea symptoms during service. The Veteran stated that his nose was persistently “runny” and that he did not seek any medical treatment. The Veteran reported that he still experienced the symptoms following separation from service. The examiner opined that the claimed disability was less likely than not incurred in or caused by service. The rationale provided was that “the acute upper respiratory infection and pharyngitis diagnosed during service in December 1967 are not a part of the clinical symptoms related to sinusitis. The sinusitis condition presents with different set of symptoms which focus mainly on the sinuses.” The examiner found that the symptoms noted in the service medical records, such as sore throat, chills, nasal congestion, and general aching with cough were not consistent with the sinusitis. The examiner highlighted that there were no noted symptoms are complaints regarding the sinuses. In a March 2020 VA examination, the Veteran reported that during service he went into the gas chamber for Army training and that was when the symptoms began. On active duty, he was treated for viremia disorder with symptoms of fever, nasal congestion, and body aches. The Veteran was noted as a chronic smoker since age 20. In 2010 he had a sinus x-ray with positive results. The Veteran also had mild septal deviation. The examiner opined that the claimed disability was less likely than not the result of active service or related to any incident in service. The rationale provided was that the Veteran’s service medical records did not note a sinusitis infection. After service, VA treatment records show several years of no pulmonary problems. In May 2010, the Veteran was referred for a pulmonary consultation due to an abnormal CT scan. The differential diagnoses included interstitial pulmonary fibrosis, hypersensitivity pneumonitis, and infectious process, pneumonitis, and likely causes were post-service exposures to mold, rugs, pigeon droppings, and penicillium notatum. The Veteran reported being a rug salesman and having birds in his backyard. At the March 2020 VA examination, the examiner opined that the Veteran’s pulmonary disability was less likely than not related to service. The rationale was that the Veteran had chronic obstructive pulmonary disease which was likely the result of smoking. He was also diagnosed with pulmonary fibrosis, which the etiology was idiopathic. The examiner noted that the Veteran had no pulmonary symptoms at that point of time and had been prescribed albuterol to be used as needed. The Veteran has confirmed service in the Republic of Vietnam. The evidence of record does not show gas chamber exposure and neither of the VA examiners provided an opinion based on possible gas exposure. An attempt should be made to verify whether or not the Veteran had gas chamber exposure during service. If so, then an addendum opinion should be obtained.. The matters are REMANDED for the following action: 1. Contact the National Personnel Records Center (NPRC) or any other appropriate entity and request the Veteran’s complete service personnel and service medical records. Efforts to locate the records should only end if the evidence, or information, does not exist or further efforts to obtain them would be futile. 38 C.F.R. § 3.159(c)(2). If appropriate records are found to be unavailable, the claims file must be properly documented as to the unavailability of these records. All available records should be associated with the claims file. 2. Take appropriate action to develop the Veteran’s claim that he was exposed to gas, to include as due to the claimed gas chamber training during active service. Document all requests and responses in the claims file. If the records do not exist or if further attempts to obtain them would be futile, then issue a formal finding of unavailability regarding the federal records and notify the Veteran. 3. Then, schedule the Veteran for a VA respiratory and sinus examination. The examiner must review the claims file and should note that review in the report. All indicated tests should be conducted. The examiner should provide a complete rationale for all opinions. The examiner should discuss the Veteran’s lay statements regarding the history and continuity of symptomatology. The examiner should indicate whether it is at least as likely as not (50 percent probability or greater) that sinusitis is related to service or any event, injury, or disease during service, to include presumed exposure to herbicide agents during service. The examiner should indicate whether it is at least as likely as not (50 percent probability or greater) that any respiratory disability is related to service or any event, injury, or disease during service, to include presumed exposure to herbicide agents during service. The examiner should indicate whether it is at least as likely as not (50 percent probability or greater) that any sinus or respiratory disability is related to gas chamber exposure during service. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Cross, 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.