Citation Nr: 21028962 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 14-19 737A DATE: May 12, 2021 ORDER Entitlement to a compensable rating for left ear hearing loss is denied. Entitlement to a separate 10 percent rating for chronic nonsuppurative otitis media, mastoiditis and cholesteatoma from March 6, 2011 is granted. Entitlement to an effective date prior to April 19, 2017 for the award of service connection of tinnitus is denied. Entitlement to a rating in excess of 10 percent for facial nerve paralysis associated with left ear hearing loss with chronic nonsuppurative otitis media is denied. REMANDED Entitlement to an extraschedular rating for left ear hearing loss with nonsuppurative otitis media, mastoiditis and cholesteatoma is remanded. Entitlement to a compensable rating for surgical scarring associated with left ear hearing loss with chronic nonsuppurative otitis media is remanded. FINDINGS OF FACT 1. The Veteran's left ear hearing loss corresponds to, at most, a Level VII numeric designation, and his right ear is not service-connected. 2. For the entire period on appeal, the Veteran has manifested mastoiditis or cholesteatoma in his service-connected left ear. 3. It is not factually ascertainable that the Veteran manifested tinnitus in his service-connected left ear prior to April 19, 2017, the date of a left ear surgery. 4. The Veteran has manifested mild to moderate numbness of the face, and has exhibited no pain and full muscle strength, most closely approximating moderate incomplete paralysis of the seventh (facial) cranial nerve. CONCLUSIONS OF LAW 1. The criteria for entitlement to a compensable rating for left ear hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.385, 4.85. 2. The criteria for a separate 10 percent rating for mastoiditis and cholesteatoma from March 6, 2011 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.310, 4.86, Diagnostic Code (DC) 6200. 3. The criteria for an effective date prior to April 19, 2017 for the award of service connection for tinnitus have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107, 5110; 38 C.F.R. §§ 3.156, 3.400, 4.3. 4. The criteria for entitlement to a rating in excess of 10 percent for facial nerve paralysis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.124a, DC 8207. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Navy from October 1981 to October 1985. This matter comes before the Board of Veterans Appeals (Board) on appeal of a June 2012 rating decision issued under the legacy system by a regional office (agency of original jurisdiction or AOJ) of the Department of Veterans Affairs (VA). The Board previously remanded the matter for further development in November 2016 and February 2018. The Veteran testified before the undersigned Veterans Law Judge at a November 2020 Travel Board hearing. In January 2020, the AOJ issued a rating decision granting entitlement to service connection for facial nerve paralysis, a surgical scar, and tinnitus due to left ear surgery; as well as a Supplemental Statement of the Case (SSOC) denying an increased rating for the Veteran's left ear on both a schedular and extraschedular basis. The Board observes that in January 2021 the Veteran's representative attempted to opt into the modernized review system, but the Form 10182 notice of disagreement was received more than 60 days after issuance of the SSOC and therefore cannot be accepted. The case has now been returned to the Board for review under the legacy system. Increased Ratings and Effective Dates Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The statutory guidelines for the determination of an effective date of an award of disability compensation are set forth in 38 U.S.C. §5110. Except as otherwise provided, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after a final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 C.F.R. § 3.400. The reference above to "the date entitlement arose" is not defined in the current statute or regulation. The Court of Appeals for Veterans Claims (Court) has interpreted it as the date when the claimant met the requirements for the benefits sought; this is determined on a "facts found" basis. See 38 U.S.C. § 5110(a); see also McGrath v. Gober, 14 Vet. App. 28, 35 (2000). These "facts found" include the date the disability first manifested and the date entitlement to benefits was authorized by law and regulation. See generally 38 C.F.R. § 3.400. However, the date entitlement arose is not the date that VA receives the evidence, but the date to which that evidence refers. McGrath, 14 Vet. App. at 35. "Claim" is defined broadly to include a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p); Brannon v. West, 12 Vet. App. 32, 34-35 (1998). The Board notes that, effective March 24, 2015, VA amended its adjudication regulations to require that all claims governed by VA's adjudication regulations be filed on standard forms prescribed by the Secretary (i.e., VA Form 21-526). 38 U.S.C. § 5101(a); 38 C.F.R. § 3.151(a). This rulemaking also eliminated the constructive receipt of VA reports of hospitalization or examination and other medical records as informal claims for increase and revised 38 C.F.R. § 3.400(o)(2). These amendments, however, are only applicable with respect to claims and appeals filed on or after March 24, 2015 and are not relevant to the present case. See 79 Fed. Reg. 57,660, 57,686 (Sept. 25, 2014). As such, any communication or action in this case, indicating an intent to apply for one or more benefits under laws administered by the VA from a claimant may be considered an informal claim. Such an informal claim must identify the benefits sought. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. Upon receipt of an informal claim, if a formal claim has not been filed, an application form must be forwarded to the claimant for execution. If the application form is received within one year from the date it was sent to the claimant, it will be considered filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155(a). To determine when a claim was received, the Board must review all communications in the claims file that may be construed as an application or claim. See Quarles v. Derwinski, 3 Vet. App. 129, 134 (1992). 1. Entitlement to a compensable rating for left ear hearing loss The Veteran asserts entitlement to a compensable rating for left ear hearing loss. Evaluations of defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of a controlled Maryland CNC speech discrimination test together with the average hearing threshold level measured by pure tone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). 38 C.F.R. § 4.85, DC 6100. An exceptional pattern of hearing loss occurs when the pure tone threshold at 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more, or when the pure tone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz. 38 C.F.R. § 4.86. If, as is the case here, impaired hearing is service connected in only one ear, the non-service-connected ear will be assigned a Roman Numeral designation for hearing impairment of I for evaluation on Table VII of the Rating Schedule. However, an exceptional pattern of hearing impairment occurs when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more. 38 C.F.R. § 4.86(a). In that situation, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. The Veteran was initially afforded a VA examination in August 2011. Audiometric testing showed pure tone thresholds, in decibels, as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 15 15 10 10 12 LEFT 30 35 45 50 41 The speech recognition scores on the Maryland CNC word list were 96 percent for the right ear, and 90 percent for the left ear. Applying the test results of the December 2016 VA examination report to Table VI of the Rating Schedule results in a Roman numeric designation of Level II for the left ear. As noted above, a Roman Numeral designation of I is automatically designated for the non-service-connected right ear. The result corresponds with a 0 percent disability rating for bilateral hearing loss. The Board notes that these tonal results on this examination did not exhibit an exceptional pattern of hearing loss in the left ear. As such, evaluation under Table VIA was not considered. The Veteran was afforded a VA examination in December 2016. The Maryland CNC Word List speech recognition scores and pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 15 20 5 5 11 LEFT 65 75 75 85 75 The speech recognition scores on the Maryland CNC word list were 94 percent for the right ear, and 66 percent for the left ear. Applying the test results of the December 2016 VA examination report to Table VI of the Rating Schedule results in a Roman numeric designation of Level VII for the left ear. As noted above, a Roman Numeral designation of I is automatically designated for the non-service-connected right ear. The result corresponds with a 0 percent disability rating for bilateral hearing loss. No other hearing examinations with audiometric evaluations are of record for this period which would result in a higher rating. The Board notes that these tonal results exhibit an exceptional pattern of hearing loss in the left ear and a higher rating under Table VIA has been considered. In this case, under this table, the Veteran would only exhibit Level VI hearing loss in the left ear, which would similarly warrant a noncompensable rating. The Veteran's most recent VA hearing examination took place in January 2019. The Maryland CNC Word List speech recognition scores and pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 30 40 30 35 34 LEFT 60 75 80 95 78 The speech recognition scores on the Maryland CNC word list were 94 percent for the right ear, and 66 percent for the left ear. Applying the test results of the April 2019 VA examination report to Table VI of the Rating Schedule results in a Roman numeric designation of Level VII for the left ear. As noted above, a Roman Numeral designation of I is automatically designated for the non-service-connected right ear. The result corresponds with a 0 percent disability rating for bilateral hearing loss. As above, rating the Veteran's hearing loss pattern as exceptional would not result in a compensable rating. No other hearing examinations with audiometric evaluations are of record for this period which would result in a higher rating. With regard to the adequacy of the 2019 examination report, the Veteran argues that there has not been substantial compliance with the previous Board remand instructions, and therefore the examination is inadequate. See Stegall v. West, 11 Vet. Ap. 268 (1998) (Where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). Per the November 2016 and February 2018 Board remands respectively, the Veteran was afforded a new VA examination in January 2019. As such, the Board finds that there has been substantial compliance with its previous remand directives. The Board recognizes that the Veteran was not afforded an examination by an otolaryngologist as suggested by the February 2018 Board remand. However, the February 2018 Board remand did not mandate that an examination by an otolaryngologist be conducted, but rather one should be conducted "if at all possible." Despite attempts by VA to comply with the remand directive, the record reflects that no otolaryngologists were available at the Veteran's treating facility to perform the requested examination. Further, the examiner who conducted the most recent examination asserted that they were qualified to provide the testing data and opinions requested by the Board in its most recent remand. As such, the Board finds there is no Stegall violation in this case. The Board has also considered the Veteran's statements that his hearing loss is worse than the ratings he receives. Martinak v. Nicholson, 21 Vet. App. 447 (2007). As such, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. While the Veteran is competent to report his impression of decreased hearing acuity, because this requires only personal knowledge as it comes to him through his senses, he is not competent to identify a specific level of his disorder according to the appropriate diagnostic code. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). In this matter, the Veteran's hearing loss requires a mechanical evaluation based on audiometric findings, per the statutory rating criteria. On the other hand, such competent evidence concerning the nature and extent of the Veteran's disorder have been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which this disability is evaluated. Therefore, the Board must base a decision on the objective medical evidence of record, which mandates a 0 percent rating for the Veteran's left ear hearing loss, and the claim for an increased rating must be denied. 2. Entitlement to a separate rating for mastoiditis and cholesteatoma of the left ear The Veteran asserts entitlement to a separate compensable rating for mastoiditis and cholesteatoma of the left ear. April 2004 private treatment records indicate the Veteran was referred to a specialist for evaluation of left ear problems. The specialist provided a pre-operative diagnosis of mastoiditis and recommended surgery, which occurred in July 2004. Post-operatively, the specialist diagnosed left chronic otitis media with tympanic membrane perforation, left middle ear cholesteatoma with deep retraction pocket, left ossicular necrosis, and left ear conductive hearing loss. A January 2019 VA examination notes the 2004 diagnosis of cholesteatoma as well as a 2017 diagnosis of mastoiditis. DC 6200 directs the Veteran's chronic nonsuppurative otitis media to be rated by hearing impairment, which is discussed above, and DC 6260 provides a noncompensable rating for perforation of the tympanic membrane. However, DC 6200 provides for a maximum 10 percent rating for chronic suppurative otitis media, mastoiditis or cholesteatoma (or any combination thereof). A Note to DC 6200 states that hearing impairment and ear complications should be rated separately. 38 C.F.R. § 4.87. As the Veteran was diagnosed with left middle ear cholesteatoma in July 2004, he is entitled to a separate 10 percent rating for this disability from March 6, 2011, the date of his claim of an increased rating for his left ear disability, as suppuration has been demonstrated chronically during the appeal period. The Veteran asserts entitlement to an effective date of at least July 6, 2004, the date of the Veteran's first left ear surgery. As noted above, for claims prior to March 24, 2015, any communication or action indicating an intent to apply for one or more benefits on the part of the claimant may be considered an informal claim. The Veteran's representative has stated that as the VA Veterans Benefits Management System (VBMS) notes a July 6, 2004 submission of the private medical record recommending surgery, this should have been interpreted as an informal claim for benefits. However, a review of VBMS indicates the recorded date is due to a transcription error committed when the document was entered into the System. It is highly unlikely the document in question, a letter from a specialist to the Veteran's referring primary physician recommending surgery, was submitted on the date it was written by the specialist. Instead, it appears this letter, as well as numerous other private medical records, were submitted as attachments to a May 2011 statement in support of the Veteran's March 2011 claim for benefits. In fact, the statement itself is clearly signed and dated "May 24, 2011" by the Veteran yet is recorded as attached to the claims file on March 18, 2005. Therefore, the Board finds that the documents marked in VBMS as submitted on July 6, 2004 and March 18, 2005, were in fact submitted in May 2011, and cannot be the basis for an informal claim for benefits. There are no further communications from the Veteran until 2011. The claims file contains a VA 21-526, Veterans Application for Compensation or Pension, identifying the Veteran's left ear disability and marked as received on March 6, 2011. This date is accurate, as one page contains the stamp of an AOJ intake official marked March 7, 2011. Thus, this is the date of the Veterans current claim for an increased rating. As noted above, the effective date of an award is the date entitlement arose or the date the claim is received, whichever is earlier. While the Veteran's entitlement to a separate rating for mastoiditis and cholesteatoma may have arisen earlier, the effective date of his claim is set by statute as the date his claim was received, March 6, 2011. 38 C.F.R. § 3.400. 3. Entitlement to an earlier effective date for the grant of service connection for tinnitus The Veteran asserts entitlement to service connection for tinnitus prior to April 19, 2017. As noted above, the AOJ issued a January 2020 rating decision granting entitlement to service connection for tinnitus from the date of the Veteran's April 2017 left ear surgery. The Veteran was assigned the maximum 10 percent rating, but his representative has argued that, as the Veteran has complained of tinnitus symptoms prior to April 2017, he is entitled to an earlier effective date. However, after a review of the record, the Board finds that an effective date prior to the date of the Veteran's left ear surgery is not warranted. The Board observes that while the Veteran's left ear has been service-connected throughout the period on appeal, his right ear is not currently service-connected. The Veteran was afforded a VA hearing examination in August 2011. The examiner noted that he reported periodic tinnitus once per month, but in the right ear only. During a December 2016 VA examination, he did not report symptoms of tinnitus in either ear. The Veteran was afforded an additional VA examination in January 2019. Among other symptoms, he reported bilateral tinnitus since ear surgery and described using a fan to drown out the constant ringing in his ears. As noted above, the effective date of an award is the date entitlement arose or the date the claim is received, whichever is earlier. While the Veteran filed a March 2011 claim of increased rating for his left ear disability, the record indicates that his left ear tinnitus first manifested after his April 2017 left ear surgery, the effective date assigned by the AOJ. Additionally, the Board observes that tinnitus was not a symptom listed in the Veteran's claim for an increased rating. As it is not factually ascertainable that the Veteran's left ear tinnitus manifested prior to his April 2017 surgery, an effective date for service connection of tinnitus prior to April 19, 2017 is not warranted. 38 C.F.R. § 3.400. 4. Entitlement to a rating in excess of 10 percent for facial nerve paralysis associated with hearing loss, left ear, with chronic nonsuppurative otitis media As noted above, during the pendency of the appeal the AOJ awarded the Veteran entitlement to service connection for facial nerve paralysis associated with left ear hearing loss, assigning a 10 percent rating from April 19, 2017. When, as here, a Veteran seeks an increased evaluation, it will generally be presumed that the maximum benefit allowed by law and regulation is sought, and it follows that such a claim remains in controversy where less than the maximum benefit available is awarded. See AB v. Brown, 6 Vet. App. 35, 38 (1993). As 10 percent is less than the maximum rating, the Board will review the rating assigned by the AOJ. The Veteran underwent April 19, 2017 left ear surgery, a side effect of which was partial paralysis of the seventh (facial) cranial nerve. He subsequently underwent an additional surgery to attempt to correct this issue, which was only partially successful. DC 8207, which deals with paralysis of the seventh (facial) cranial nerve, provides a 30 percent rating for complete paralysis of the facial nerve, a 20 percent rating for severe incomplete paralysis, and a 10 percent rating for moderate incomplete paralysis. Although the DC does not discuss the definition of the terms "moderate" or "severe," a note states the rating shall be "dependent upon relative loss of innervation of facial muscles." 38 C.F.R. § 4.124a. The Veteran was afforded a VA cranial nerve examination in January 2019. The examiner noted damage to the Veteran's cranial nerve during left ear surgery as well as his reported symptoms including facial numbness, constant ringing of the ears, difficulty hearing, and occasional popping. The Veteran described his main complaint as decreased hearing acuity in his left ear. Upon examination, the examiner recorded moderate numbness on the mid-left side of the face, mild numbness of the lower-left side of the face, and decreased sensation in the mid-face. Muscle strength was normal, as was sensation in the left-upper and left-lower face. There was no evidence of right cranial nerve impairment, and the examiner opined that the Veteran's incomplete facial nerve paralysis did not impact his ability to work. Based on the evidence of record, the Board finds that the Veteran's seventh cranial nerve impairment most closely approximates moderate incomplete paralysis. The January 2019 examiner recorded, at most, moderate numbness of part of the left side of the face, as well as no more than mild decreased sensation of part of the face. This correlates with the Veteran's lay description of numbness from behind the ear to just below the ear. The next higher rating, 20 percent, is only warranted if there is severe incomplete paralysis of the facial cranial nerve. As the Veteran did not report any symptoms of pain or paresthesias/dysesthesias, exhibited full muscle strength, and his main complaint was decreased hearing acuity, the Board finds that he exhibits, at most, moderate impairment of the seventh cranial nerve. REASONS FOR REMAND 1. Entitlement to an extraschedular rating for left ear hearing loss with chronic nonsuppurative otitis media is remanded. The Veteran asserts entitlement to an extraschedular rating for his left ear disability. The Board observes that consideration for an extraschedular rating has been referred to referred to the Director of Compensation Service (Director) and an opinion was issued in March 2017, in accordance with 38 C.F.R. § 3.321(b). The Director issued an Administrative Decision which determined that the Veteran was not entitled to a compensable rating for left ear hearing loss on an extraschedular basis, stating that his service-connected disability did not present an exceptional or unusual disability picture. The decision reasoned that the medical evidence of record showed no significant limitations, to include marked interference with employment or frequent periods of hospitalization, so as to render the application of the regular schedular standards impractical. After the Director has considered the issue in the first instance, the Board has an opportunity to evaluate the claim, and is not bound by the Director's decision. Wages v. Shinseki, 27 Vet. App. 233 (2015). However, in this case the November 2016 Board remand that instructed the AOJ to forward the claim to the Director of for extraschedular consideration noted the Veteran's four prior left ear surgeries. The Board observes that the Director's March 2017 opinion only referenced one surgery and ignored the other employment limitations described in the Board remand. Normally, the Board would remand the claim to the AOJ in order to ensure compliance with the prior remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). However, since the prior Board remand, the case law regarding referral for extraschedular consideration has changed. As such, the Board must determine whether extraschedular referral is warranted under the new guidelines set out by the Court in interpreting 38 C.F.R. § 3.21(b). The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extra-schedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extra-schedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Previously, this meant there was a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. However, the Court held in Morgan v. Wilkie, 31 Vet. App. 162, 168 (2019), that extraschedular consideration is appropriate only after the agency has exhausted all other tools for a disability rating, whether direct, secondary, or analogous ratings. The Court noted that focusing "on the full scope of schedular rating devices will significantly reduce the need to address extraschedular referral, reserving it for those cases that are truly 'exceptional.'" Id. As such, "exceptionality"as interpreted via Thun's first stepmust be viewed in the context of all available rating tools and cannot be reduced to a mere comparison of a veteran's symptomatology with the language of a particular diagnostic code. See, e.g., Spellers v. Wilkie, 30 Vet. App. 211, 218 (2018). A symptom cannot be deemed exceptional (and satisfy Thun's first step) where it is capable of evaluation by conventional rating means). By way of history, the Veteran has worked at a grocery store since 2000. Prior to the period on appeal, he underwent 2004 left ear surgery for otitis media with tympanic membrane perforation, middle ear cholesteatoma with deep retraction pocket, and ossicular necrosis with conductive hearing loss. Employment records attached to November 2020 correspondence indicate he was on disability leave for one week following the surgery with an additional week of restricted duty. In June 2011, VA audiometric testing revealed decreased left-ear hearing acuity, and December 2011 private treatment records indicate tubing inserted into his ears were not likely to remain in place, resulting in a permanent perforation. August 2013 VA treatment records indicate several significant ear infections over the prior six months, and the Veteran underwent a second surgery in December 2014. According to the November 2020 hearing transcript, this surgery was a left tympanomastoidectomy, which the Veteran testified required the complete removal of his outer ear and included lysis of adhesions as well as a facial nerve monitor. Employment records indicate no disability claim on file, and their attendance records (tracking non-disability leave) do not reach back that far. The Veteran underwent additional surgeries in February and August 2016 for tympanic membrane perforation and left adhesive otitis media, and hearing testimony indicates he experienced excessive bleeding during the second surgery. Employment records indicate he was granted disability leave for 26 days following the February surgery, with no record of a disability claim following the August surgery. However, the Veteran testified at the Board hearing that he used two weeks of sick and vacation leave following the August surgery. VA treatment records indicate the Veteran experienced worsening hearing loss following the 2016 surgeries, and he underwent an additional surgery in April 2017. This surgery was a left tympanoplasty and mastoidectomy which the Veteran testified required complete ear removal and resulted in facial nerve damage as well as constant tinnitus. He underwent yet another surgery in February 2018 to repair facial nerve damage incurred in the April 2017 surgery. Employment records indicate approved disability leave for 28 days and 25 days following his April 2017 and February 2018 surgeries, respectively. In February 2021 correspondence, the Veteran's representative noted that due to his left ear disability, his employer has to ensure he does not work in cold areas and must prevent his exposure to loud noises. This prevents him from working in the refrigerator or freezer sections, as well as the stock area where forklifts operate, limiting him to the front areas of the store. The representative further noted that the Veteran had to leave work on short notice when his ear tubes fell out, which according to the hearing transcript the Veteran attested to on numerous occasions. Finally, the Veteran also testified that his severe left ear hearing impairment has markedly interfered with his ability to interact with customers and colleagues in the areas of the store in which he is able to work. VA treatment records throughout the appeal period confirm that the Veteran has regularly complained about the effectiveness of his left ear hearing aid as well as decreased hearing acuity. In this case, the Board finds that the Veteran's left ear disability meets the requirement of "exceptionality" as described by the Court. While Veteran has separate compensable ratings for several of his secondary symptoms, such as tinnitus and facial nerve impairment, these ratings do not adequately describe the severity or functional impact of the Veterans symptoms. The Board has considered assigning additional separate ratings by analogy to compensate his additional symptomatology, but as he does not manifest Meniere's syndrome or a peripheral vestibular disorder and has had his auricle removed but then reattached, the remaining DCs related to the ear are inappropriate. Furthermore, there is not an available DC to rate his countless painful, purulent and draining ear infections and the unsuccessful placement of multiple tubes in his ear. Noting the Veteran's five ear surgeries and subsequent recovery times during the appeal period, the Board has considered the assignment of temporary total disability ratings for surgeries that require a convalescence period. However, 38 C.F.R. § 4.30(a) only authorizes the assignment such a rating when the surgery results in at least one month of convalescence, and, as noted above, the Veteran's convalesce periods were on average slightly shorter than one month. The Board finds that there is no adequate way within the Ratings Schedule to compensate the Veteran for his symptomatology, to include reduced ability to complete work tasks, limited areas of assignment, and the loss of employment time due to surgeries and clinic visits to treat complications from his disabilities. Similarly, as detailed above, the Board finds that the Veteran's service-connected left ear presents an exceptional disability picture, to include marked interference with employment and numerous hospitalizations. As such, it is in the interest of justice to refer his claim for further extraschedular consideration by the Director. 2. Entitlement to a compensable rating for surgical scars associated with left ear hearing loss with chronic nonsuppurative otitis media is remanded. The Veteran asserts entitlement to a higher rating for scars associated with the numerous surgeries performed to alleviate his left ear hearing loss with chronic nonsuppurative otitis media as well as his cholesteatoma and mastoiditis. As noted above, the AOJ granted entitlement to service connection for scarring related to an April 2017 surgery, assigning a noncompensable rating from April 19, 2017. In February 2021 correspondence, the Veteran's representative claimed entitlement to higher ratings due to scarring of the face and ears as well as an earlier entitlement date, based on scarring from a December 2014 left ear surgery. As noted above, it is assumed that a Veteran claiming an increased rating is seeking the maximum benefit. See AB, 6 Vet. App. at 38. The Board observes that during the period on appeal, the Veteran underwent left ear surgeries in December 2014, February 2016, August 2016, and April 2017, as well as facial surgery to repair nerve damage in February 2018. The Board further observes that the Veteran has not been afforded a VA scar examination, and prior VA examinations do not clearly indicate the nature and severity of the Veteran's ear and facial scarring. Therefore, remand for such an examination is required. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (the passage of time alone, without an allegation of worsening, does not warrant a new examination. However, a material change in the condition or problems/inconsistencies in the prior examination(s) can so warrant). The matters are REMANDED for the following action: 1. Refer the issue of entitlement to an extraschedular rating for the Veteran's left ear disability to the Director of Compensation Service for consideration of an extraschedular rating under 38 C.F.R. § 4.16(b). The Director's attention is invited to the Veteran's medical records indicating five left ear surgeries during the appeal period, hearing testimony detailing his numerous employment difficulties (including missed time and inability to be assigned various areas/duties), correspondence describing repeated painful, draining and purulent ear infections and employment records cataloguing his use of short term disability leave. 2. Schedule the Veteran for a VA examination to determine the current number, nature and severity of ear and facial scars related to his service-connected disabilities. The examination should, as warranted, address all symptoms and functional limitations. The examiner must state whether any of the service-connected scars demonstrate any characteristics of disfigurement. The electronic claims file must be available to the examiner and the examiner must specify in the examination report that these records were reviewed. The examiner's attention is directed to medical records documenting September 2004, December 2014, February 2016, August 2016, April 2017 ear and February 2018 facial surgeries. T. MAINELLI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. C. Schumacher, 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.