Citation Nr: 22016108 Decision Date: 03/21/22 Archive Date: 03/21/22 DOCKET NO. 18-02 396 DATE: March 21, 2022 ORDER 1. Entitlement to service connection for a right thumb disability, to include degenerative changes and arthritis, is denied. REMANDED 2. Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected chronic sinusitis and service-connected allergic rhinitis, is remanded. FINDING OF FACT A right thumb disability, to include degenerative changes and arthritis, did not have its onset in service, was not manifested within one year of service discharge, and is not otherwise related to service. CONCLUSION OF LAW The criteria for service connection for a right thumb disability, to include degenerative changes and arthritis, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Air Force from July 1967 to January 1971 and from March 1971 to September 1990. In October 2021, the Veteran and his wife testified at a virtual hearing before the undersigned Veterans Law Judge. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran 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 present disability and the disease or injury incurred or aggravated during service. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Where a veteran served 90 days or more of active service, and certain chronic diseases, such as arthritis, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). 1. Entitlement to service connection for a right thumb disability, to include degenerative changes and arthritis At the October 2021 Board hearing, the Veteran testified that his right thumb disability was incurred during service in 1972 while he was stationed in South Korea, when he slipped on concrete and bent his thumb backwards at a location known as "Site 91." The Veteran stated that he did not have access to immediate medical care after the injury, and later thought his thumb injury was not severe enough to warrant medical treatment later during service. The Veteran reported that his right thumb is now manifested by arthritis and visible derangement. The Board has carefully reviewed the evidence of record and finds that the evidence persuasively weighs against the award of service connection for a right thumb disability on a direct or presumptive basis. The reasons follow. The Veteran has been diagnosed with a right thumb disability, and thus there is evidence of a current disability. For example, in a September 2004 private treatment record the Veteran was diagnosed with first proximal phalangeal subluxation on the first metacarpal head, abnormal articulation, and early degenerative changes in the first metacarpal joint space. In a January 2018 private treatment record, diagnostic testing revealed that the Veteran had advanced degenerative changes involving the first metacarpal phalangeal joint space. Thus, the facts establish that the first element of a service-connection claim is met. As to evidence of an in-service disease or injury, the Veteran states that he sustained an injury to his right thumb in 1972 while stationed in South Korea. While the Veteran is competent to allege an injury to his right thumb, the service treatment records dated after 1972 do not support a right thumb disease or injury in 1972 or a subsequent deformity. For example, an October 1975 Report of Medical Examination shows that clinical evaluation of the upper extremities was normal. The examiner documented a discussion of other medical issues, such as the pain in the left knee since July 1975 and pain in the right shoulder when assuming certain positions, but did not document findings or complaints related to the Veteran's right thumb. An October 1979 Report of Medical Examination also noted a normal clinical evaluation of the upper extremities, and the examiner documented that there were no significant changes since the last physical examination. In a July 1983 diving physical, the examiner documented that the Veteran had no medical problems, and the examination was unremarkable except for left ear symptoms. In an August 1986 service treatment record, it was noted that that the Veteran was qualified for worldwide duty without medical restrictions. The Veteran's upper extremities were found to be clinically normal in a November 1983 Report of Medical Examination, and again in September 1988. The September 1988 Report of Medical Examination documented the Veteran's other injuries, such as his right shoulder injury in 1985, fractured right ankle in May 1986, and fractured left ankle in July 1987, and the examiner explained how each of these injuries occurred. The examiner documented that the Veteran affirmed, and a review of his medical records showed, that there was not any other significant medical history since the last physical examination in November 1983. In an October 1989 Dental Patient Medical History, the Veteran described his present health as "excellent." In the July 1990 Report of Medical Examination, which was performed at the time of the Veteran's retirement, abnormal findings were noted in his right shoulder only, but no other abnormal clinical findings in the upper extremities were documented. The above-described examinations represent 15 years of the Veteran's upper extremities being clinically evaluated by multiple medical professionals and denote numerous other medical conditions and symptoms, but do not support complaints or findings related to a disease or injury involving the Veteran's right thumb. The Board finds that had the Veteran experienced a right thumb injury, he would have reported it in the context of reporting other injuries of similar, or lesser severity during service. In other words, just because the Veteran did not seek treatment at the time of the injury would not have prevented him from reporting subsequent right thumb symptoms, including a deformity after the injury that he alleges developed while he was still in service. For example, in a February 1990 service treatment record, the Veteran reported a right toe injury on his foot five days prior. This record establishes that the Veteran sought care for other medical issues and shows that the Veteran sought medical care for problems even though they were incurred several days prior. Documented throughout the service treatment records are reports of bilateral ankle injuries and right shoulder strain with ongoing symptoms and various other medical symptoms, such as a rash, vision issues, back injury, sinusitis, rhinitis, conjunctivitis, hearing loss, ear infection, and other medical symptoms. What is not documented in the hundreds of pages of service treatment records are complaints involving the right thumb, whether an injury or a subsequent deformity. In the July 1990 Report of Medical History at the time of the Veteran's retirement from service, he denied a history of swollen or painful joints; bone, joint or other deformity; and the loss of finger, which does not support the allegation that he sustained a right thumb disease or injury in service that developed into a deformity. The Veteran also denied any illness or injury other than those already noted within the form. In the Notes section, the examiner documented the Veteran's history of chickenpox, mumps, measles, prescription glasses, hay fever, high blood pressure, broken left forearm in 1964, right shoulder injury in 1985, right ankle injury, and left ankle injury in 1987, but did not document a right thumb injury in 1972 or during service. The positive reports within the Report of Medical History is consistent with what is documented in the service treatment records. The fact that the Veteran affirmatively denied any illness or injury other than those already noted, denied a history of symptoms related to his joints, bones, and finger, including a joint deformity, while he reported multiple musculoskeletal injuries involving his left forearm, right ankle, left ankle, and right shoulder, is evidence against an in-service right thumb disease or injury. It does not make sense that the Veteran would have reported multiple injuries to various parts of his musculoskeletal system that involved both the upper and lower extremities and not report an in-service right thumb injury with subsequent deformity if the injury had occurred during service in 1972 and the deformity developed while still in service, as alleged by the Veteran and his wife. In PULHES evaluations from February 1975, October 1975, October 1979, August 1983, November 1983, August 1985, August 1986, and September 1988, the Veteran was assigned a "1" for "U" in each instance. The "U" stands for "Upper Extremities." This factor concerns the hands, arms, shoulder girdle, and upper spine (cervical, thoracic, and upper lumbar) in regard to strength, range of motion, and general efficiency. An individual having a numerical designation of "1" under any factor is considered to possess a high level of medical fitness for that category. As the Veteran was shown to have a high level of medical fitness on multiple occasions for more than 10 years throughout the period of service that he claims he sustained the in-service injury, this weighs against a finding that the Veteran was experiencing right thumb symptoms during service. Accordingly, for all these reasons, the Board finds that the contemporaneous records do not support a right thumb disease or injury in 1972, and the Board finds that such allegations by the Veteran and his wife are not credible. This is not a situation where the evidence is silent for a left thumb disease or injury but where the Veteran was physically examined for 15 years, from 1975 to 1990, which showed normal clinical evaluations of the upper extremities (except the shoulder in 1990), and where he denied a joint deformity at service discharge in July 1990 within the Report of Medical History. The Board finds that this is affirmative evidence against a right thumb disease or injury during service, and the in-service disease or injury element is not met. Additionally, the evidence persuasively weighs against a nexus between the right thumb disability and service. For example, in a November 1990 VA examination report, the Veteran's medical problems were documented, and included complaints related to his bilateral ankle and right shoulder, which is consistent with what he documented in the July 1990 Report of Medical History, but do not include a reference to a right thumb injury or right thumb symptoms. Additionally, the Veteran underwent a physical examination at that time, which showed no musculoskeletal findings related to his thumb, although shoulder and bilateral ankle problems were documented. As the physical examination of the Veteran's musculoskeletal system soon after service separation did not reveal right thumb symptoms, including a deformity, this evidence further supports a finding that the Veteran's right thumb disability did not have its onset in service. A July 2003 private treatment record shows the Veteran reported a history of a cramp in his left hand, but did not report issues related to his right thumb. At this point, it had been approximately 13 years following service discharge, and the Veteran was not reporting right thumb symptoms or a deformity. This further supports the finding that the post-service right thumb disability is not related to service. In a September 2004 VA treatment record, the Veteran first complained of symptoms related to his thumb. He reported that he injured his thumb many years ago but did not contend that that the injury occurred during service. This evidence does not support a finding that the Veteran's right thumb disability is related to or otherwise incurred in service. In the April 2017 Notice of Disagreement, the Veteran contended that he injured his right thumb during service, and that his disability was manifested by visible symptoms continuously since service. In the January 2018 VA Form 9, Appeal to the Board, the Veteran contended that his wife witnessed the changes in his right thumb. In a VA Form 646, Statement of Accredited Representative, the Veteran, through his representative, contended that he and his wife are competent to note their observations that the Veteran's right thumb disability was acquired on active duty and has been present since that time. At the October 2021 Board hearing, and in an October 2021 statement, the Veteran stated that he incurred his right thumb disability during service in South Korea in approximately 1972. The Veteran stated that his thumb was visibly deformed and noticeably out of its joint, and that he developed pain, stiffness, loss of grip strength, incoordination, and other functional loss in his right thumb joint within one year of separation from service. He also reported that he currently experiences ongoing pain and arthritis in the right thumb. The Veteran's wife stated that she observed the onset of the condition during service. The Veteran contends that the evidence of continuous symptoms since service establishes that his right thumb disability was incurred in or otherwise related to service. The Veteran also contends that the absence of corroborating records is an insufficient basis upon which to deny that lay statements are credible. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). However, in the instant case, the Board finds that the evidence of record, including medical examinations during service that cover a 15-year period, the July 1990 Reports of Medical Examination and Medical History, and the November 1990 VA examination report after service affirmatively establishes that the Veteran did not incur a right thumb disease or injury during service. The Board accords the most probative value to the statements made by the Veteran within the service treatment records, wherein he specifically denied a history of swollen or painful joints; denied a history of bone, joint or other deformity; denied the loss of finger; and denied any illness or injury other than those already noted, in the July 1990 Report of Medical History, which was approximately two months before his service discharge. As discussed above, in the same record, he documented other medical complaints he had experienced during service, including other musculoskeletal symptoms, which did not include a right thumb disease, injury, or deformity. The record also shows that numerous medical evaluations of the Veteran's upper extremities, between 1975 and 1990, all of which were performed after the alleged injury, revealed normal clinical findings (again, except for the right shoulder) and/or a high level of medical fitness involving the upper extremities. Additionally, these records are afforded more probative value, as they were created contemporaneously with the Veteran's service and within the context of medical evaluation, and the Board finds that the Veteran would have been motivated to disclose any medical problems with his right thumb, especially when he reported other musculoskeletal problems, such as with his right shoulder, right ankle, and left ankle. Accordingly, the Board finds that the Veteran's and his wife's contentions as to an in-service right thumb injury and subsequent deformity while in service are not credible. To reiterate, this is not a situation where the evidence is silent for a right thumb disease or injury but where the Veteran was physically examined for 15 years while still in service, and he documented multiple musculoskeletal symptoms he had experienced, which did not include a right thumb injury, disease, or deformity, and where he specifically denied a joint deformity at service discharge. The Board finds no reason to question the accuracy of what the Veteran documented within the July 1990 Report of Medical History, as he completed it contemporaneously with service, the documented facts were consistent with clinical findings documented throughout the service treatment records, and he certified the truth of such statements, all of which make these facts highly credible. As to presumptive service connection for chronic disease, the Board finds that the Veteran did not incur an injury or disease related to his current right thumb in service and that arthritis was not manifest during service or within one year of separation from service. Furthermore, the evidence of record does not demonstrate that the Veteran's symptoms have been continuous since separation from service. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). There were no complaints, diagnosis, or treatment for this disorder for approximately 14 years following service discharge until the Veteran was sought treatment for a right thumb disability in September 2004. Although at the time of the September 2004 record, the Veteran reported that he injured his right thumb many years ago, he did not attribute this injury to service, and the July 1990 Reports of Medical Examination and Medical History and the November 1990 VA examination report demonstrated that the Veteran was not complaining of right thumb problems, or a reporting a history of a right thumb injury, at the time these examinations were performed, while at the same time reporting other musculoskeletal symptoms he had been experiencing since the 1980s. Accordingly, the September 2004 private treatment record does not support that the right thumb disability was continuous since separation from service. The absence of post-service complaints, findings, diagnosis, or treatment for approximately 14 years after service is one factor that tends to weigh against a finding of continuous symptoms since service separation. The Board may weigh the absence of contemporaneous medical evidence as one factor in determining credibility of lay evidence. A prolonged period without medical complaint can be considered, along with other factors, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability. While the Veteran and his wife allege that the right thumb disability had its onset in service, the Board has already explained why it finds there was no in-service disease or injury related to the right thumb. The Board is not addressing whether the Veteran's wife is competent to enter a diagnosis, but rather that the Veteran's wife's allegation that the Veteran had a right thumb deformity while in service is not credible. At the present time, there is no credible evidence of an in-service disease or injury and no competent and credible evidence of a nexus between the right thumb disability and an in-service disease or injury. Accordingly, the evidence persuasively weighs against both an in-service disease or injury and a nexus between the post service right thumb disability and service. VA did not provide the Veteran with a VA examination and/or medical opinion in connection with this claim. VA must provide a medical examination and/or medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Here, for the reasons described above, the Board finds both that there was not an event, injury, or disease that occurred in service, or that a right thumb disability manifested during the one-year period following service discharge. The evidence also does not establish a right thumb disability may be associated with the Veteran's service. These findings of fact have been explained above in detail. For a VA examination and/or medical opinion to be warranted, all the McLendon criteria have to be met, and at least one of the criteria is not met. Therefore, entitlement to a VA examination and/or medical opinion is not warranted. For the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether service connection for a right thumb disability, to include degenerative changes and arthritis, is warranted. Rather, the evidence persuasively weighs against service connection. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). REASONS FOR REMAND 2. Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected chronic sinusitis and service-connected allergic rhinitis. At the October 2021 Board hearing, the Veteran testified that he became aware of sleep issues during the 1980s while serving in Germany. He reported that his wife witnessed symptoms of sleep apnea during service, and that his private doctor opined that his sleep apnea began during service. In a January 2018 private opinion, Dr. W.M. Johnson opined that that the Veteran's sleep apnea is directly related to service and is related to service-connected allergic rhinitis and service-connected chronic sinusitis. Dr. Johnson explained that sleep apnea can have insidious onset with diagnosis occurring many years later. He also noted that the Veteran reported continuous symptoms of sleep apnea, which the Veteran stated was observed by others. Dr. Johnson also stated that allergic rhinitis is linked to obstructive sleep apnea. He stated that the Veteran's history and recent assessment represent the most commonly experienced way sleep apnea is diagnosed, documenting that the Veteran had some elevated blood pressure and acute respiratory conditions during service. Dr. Johnson also referenced research that he stated supported a connection between diabetes and sleep apnea, as well as between rhinitis and sleep apnea. However, while Dr. Johnson referenced symptoms of high blood pressure and respiratory issues during service, he did not state if, or how, these symptoms are related to obstructive sleep apnea. Dr. Johnson also did not discuss relevant service records, such as the Veteran's July 1990 Report of Medical History, where the Veteran denied a history of frequent trouble sleeping, and did not report a history of any other sleep problems. Finally, although Dr. Johnson referenced "attached" research that supported a connection between rhinitis and sleep apnea, the evidence does not support that such research was provided. For all these reasons, the Board finds that the January 2018 private opinion is inadequate. In a March 2018 VA opinion, the examiner opined that the Veteran's obstructive sleep apnea less likely than not incurred in or caused by active military service. The examiner provided the rationale that the Veteran was diagnosed with sleep apnea by sleep study in 2008, which was approximately 18 years following separation from service. The examiner also noted that the Veteran's service records do not support complaints of problems related to sleep, and that the Veteran denied a history of sleeping problems in the July 1990 Report of Medical History. The March 2018 examiner also opined that the Veteran's obstructive sleep apnea is not proximately due to or aggravated beyond its natural progression by the service-connected allergic rhinitis. The examiner provided the rationale that allergic rhinitis does not cause or impact obstructive sleep apnea. Instead, the examiner explained that obstructive sleep apnea is caused by pharyngeal tissue collapse in upper airway. The March 2018 VA opinion does not discuss whether the Veteran's obstructive sleep apnea is caused or aggravated by the service-connected chronic sinusitis. Accordingly, this issue must be remanded to obtain an addendum opinion. In an October 2021 statement, the Veteran's wife, Mrs. [REDACTED] opined that the Veteran's obstructive sleep apnea began during service and is otherwise related to service, explaining that she observed that the Veteran experienced sleep issues, including snoring and stopped breathing. The Veteran contends that Mrs. [REDACTED] can provide a medical opinion because she is a registered nurse. However, the Board finds that this opinion has an insufficient rationale and provides conclusory statements as to the Veteran's obstructive sleep apnea. The matter is REMANDED for the following action: Obtain an opinion from an appropriate clinician to determine the nature and etiology of the Veteran's obstructive sleep apnea. If the examiner believes that an in-person examination is necessary to provide an informed opinion, then schedule an examination. The agency of original jurisdiction is asked to provide a copy of the below facts to the examiner. To assist in a review of the claims file, the examiner is informed of the following facts with citations in the record, when applicable: The Veteran served on active duty from July 1967 to January 1971 and from March 1971 to September 1990. The Veteran is service-connected for chronic sinusitis and allergic rhinitis. The Veteran was diagnosed with obstructive sleep apnea in May 2008 and is claiming that it is caused or aggravated by the service-connected chronic sinusitis and/or allergic rhinitis. The Veteran also contends that his obstructive sleep apnea began during service and has been continuous since service. The Veteran's wife, a registered nurse, states that she witnessed him snoring and struggling with breathing while sleeping and that he experienced problems with fatigue prior to discharge from service. An October 1979 Report of Medical Examination shows that the examiner documented that the Veteran's tonsils were removed in childhood. See VBMS entry with document type, "STR Medical," receipt date 07/24/2014, with "#4" in the subject field, p. 24 (item 21). A July 1990 Report of Medical Examination performed at service retirement shows that clinical evaluation of the mouth and throat were anormal with a notation that the Veteran's tonsils were enucleated. See VBMS entry with document type, "STR Medical," receipt date 07/24/2014, with "#4" in the subject field, p. 2 (item 21). In a July 1990 Report of Medical History, completed at service retirement, the Veteran denied a history of frequent trouble sleeping. The report provided a detailed description of medical issues, which did not include fatigue or sleep issues. See VBMS entry with document type, "STR Medical," receipt date 07/24/2014, with "#4" in the subject field, at p. 4 (item 11, last column). A September 2004 military facility treatment record shows that the Veteran had been prescribed Fluticasone (Flonase) and Loratadine (Claritin) for allergic rhinitis. See VBMS entry with document type, "Medical Treatment Record Government Facility," receipt date 03/17/2016, with "#4" in the subject field, p. 180. An August 2005 military facility treatment record shows that the Veteran's "problems" included allergic rhinitis due to pollen. Active medications included Fluticasone (Flonase) and Cetirizine (Zyrtec). See VBMS entry with document type, "Medical Treatment Record Government Facility," receipt date 03/17/2016, with "#4" in the subject field, p. 177. A December 2006 military facility treatment record shows that the Veteran was seen with severe head and chest congestion with cough. When addressing the Veteran's "problems," the examiner included allergic rhinitis. The Veteran denied nasal discharge, nasal passage blockage, and sneezing, but reported a sore throat on the left side. He denies sinus pain. Physical examination showed no nasal discharge or sinus tenderness. The pharynx had no exudate and was not inflamed. The assessment was bronchitis. See VBMS entry with document type, "Medical Treatment Record Government Facility," receipt date 03/17/2016, with "#4" in the subject field, pp. 170-171. A March 2008 military facility treatment record shows the Veteran reported excessive daytime somnolence and falling asleep easily during day. The Veteran's wife stated that the Veteran seemed to stop breathing while sleeping occasionally and noted some snoring. The examiner noted that he would order a sleep study. See VBMS entry with document type, "Medical Treatment Record - Government Facility," receipt date 03/17/2016, with "#4" in the subject field, at p. 160. An April 2008 military facility treatment record shows that the Veteran was complaining of painful cough and chest congestion despite over-the-counter medication. The Veteran denied sinus pain and nasal discharge. He reported nasal passage blockage at night and mild sore throat. The examiner noted the Veteran had rhinorrhea with mucous in turbinates. There was no sinus tenderness, no tenderness of maxillary sinus, and no frontal sinus tenderness. The posterior pharyngeal wall was not erythematous and did not have an exudate. The Veteran was diagnosed with an upper respiratory infection. See VBMS entry with document type, "Medical Treatment Record Government Facility," receipt date 03/17/2016, with "#4" in the subject field, pp. 156-158. A May 12, 2008 sleep study shows the Veteran was described as a 59-year-old male undergoing a PAP titration study. The sleep study shows an interpretation of severe sleep disordered breathing that failed CPAP but responded well to bi-level pressures of 12/7 cm, but which may not be definitive given the persistence of flow limitation. See VBMS entry with document type, "Medical Treatment Record Non-Government Facility," receipt date 03/17/2016, with "#7" in the subject field, pp. 5-9. A May 13, 2008 military facility treatment record shows that the Veteran was seen with complaints of developing a cough after medication change and that over-the-counter medicine was not helping. The Veteran reported that after the upper respiratory infection episode, his cough had not resolved. He expressed wondering if it might be related to Micardis. The examiner noted that the Veteran was currently taking Zyrtec for seasonal allergic rhinitis. The examiner documented the cough was worse at night and better in the morning, and the Veteran had a hard time sleeping. The examiner entered an assessment of allergic rhinitis and that he suspected the cough was related to seasonal allergic rhinitis. The examiner noted that the Veteran had done better on Allegra in the past and would switch the medication. The examiner documented that Cetirizine would be discontinued. See VBMS entry with document type, "Medical Treatment Record Government Facility," receipt date 03/17/2016, with "#4" in the subject field, pp. 153-155. An August 2008 miliary facility treatment record shows that when performing a review of systems, the examiner documented that the Veteran had no nasal discharge, no nasal passage blockage, no snoring, no sneezing, and no sore throat. See VBMS entry with document type, "Medical Treatment Record Government Facility," receipt date 03/17/2016, with "#4" in the subject field, p. 151. A January 2009 military facility treatment record shows that the Veteran was there to be evaluated for a transient ischemic attack. The Veteran reported feeling confused at the end of the prior week. He denied sinus pain and sinus pressure an denied otolaryngeal symptoms. ENT examination was normal. See VBMS entry with document type, "Medical Treatment Record Government Facility," receipt date 03/17/2016, with "#4" in the subject field, pp. 136-137. A March 2011 military facility treatment record shows that when performing a review of systems, the examiner documented that the Veteran had no nasal discharge, no nasal passage blockage, and no sore throat. Physical examination showed no nasal discharge, and the posterior pharyngeal was normal. See VBMS entry with document type, "Medical Treatment Record Government Facility," receipt date 03/17/2016, with "#4" in the subject field, pp. 111-112. An October 2011 military facility treatment record shows that the examiner documented that Allegra would be replaced with Singular and that the Veteran should continue using Flonase. See VBMS entry with document type, "Medical Treatment Record Government Facility," receipt date 03/17/2016, with "#4" in the subject field, pp. 102-105. A November 2012 military facility treatment record shows that when performing a review of systems, the examiner documented that the Veteran had no otolaryngeal symptoms. Physical examination showed normal oropharynx. The examiner documented that the Veteran was using prescriptions for the allergic rhinitis with good results and would continue. The examiner documented that the Veteran denied any side effects or complications. See VBMS entry with document type, "Medical Treatment Record Government Facility," receipt date 03/17/2016, with "#4" in the subject field, pp. 87-91. A July 2013 military facility treatment record shows that the Veteran was back on Allegra. See VBMS entry with document type, "Medical Treatment Record Government Facility," receipt date 03/17/2016, with "#4" in the subject field, p. 79. In March 2016, the Veteran submitted an article entitled, "Identifying and Treating OSA." The article notes that the symptoms of sleep apnea include snoring, high blood pressure, and gasping or choking during sleep. See VBMS entry with document type, "Buddy / Lay Statement" receipt date 03/17/2016, at p. 2. A January 2017 VA examination report shows diagnoses of chronic sinusitis and allergic rhinitis. The examiner noted that the Veteran had episodes of sinusitis, which were non-incapacitating and which were characterized by headaches, pain and purulent discharge or crusting in the last 12 months. The total number of non-incapacitating episodes was 7 or more for a 12-month period. The examiner documented that the Veteran did not have incapacitating episodes of sinusitis in the last 12 months. The examiner noted the Veteran had not undergone surgery, and that the Veteran did not have greater than 50% obstruction of the nasal passage on both sides due to rhinitis. The examiner wrote there was permanent hypertrophy of the nasal turbinates, but there were no nasal polyps. The examiner documented that the Veteran did not have granulomatous conditions. The examiner wrote that the Veteran's sinus, nose, throat, larynx or pharynx condition did not impact his ability to work. See VBMS entry with document type, "C&P Exam," receipt date 01/04/2017, with "DBQ ENT," in the subject field. In a January 2018 private opinion, Dr. W.M. Johnson opined that that the Veteran's sleep apnea is directly related to service and is related to service-connected allergic rhinitis and service-connected chronic sinusitis. Dr. Johnson also stated that allergic rhinitis is linked to obstructive sleep apnea. He wrote that the Veteran's history and recent assessment represent the most commonly experienced way sleep apnea is diagnosed, documenting that the Veteran had some elevated blood pressure and acute respiratory conditions during service. Dr. Johnson also referenced research that supported a connection between diabetes and sleep apnea, as well as between rhinitis and sleep apnea, but did not provide copies of this research. See VBMS entry with document type, "Disability Benefits Questionnaire (DBQ) - Veteran Provided," receipt date 01/30/2018, pp. 2 3. In a March 2018 opinion, the examiner opined that the Veteran's sleep apnea was less likely than not incurred in or caused by active military service. The March 2018 examiner also opined that the Veteran's sleep apnea is not caused or aggravated beyond its natural progression by the service-connected allergic rhinitis. The examiner explained that obstructive sleep apnea is caused by pharyngeal tissue collapse in the upper airway. See VBMS entry with document type, "Email Correspondence," receipt date 03/08/2018. The March 2018 VA opinion does not discuss whether the Veteran's obstructive sleep apnea is caused or aggravated by the service-connected chronic sinusitis and allergic rhinitis. Rather the examiner addressed only whether allergic rhinitis caused or aggravated the obstructive sleep apnea. Additionally, the examiner provided a minimal explanation for how he reached this opinion. In an October 2021 statement, the Veteran's wife, a registered nurse, opined that the Veteran's obstructive sleep apnea began during service. See VBMS entry with document type, "Correspondence," receipt date 10/01/2021, at p. 4. The examiner's review of the record is NOT restricted to the evidence listed above. This list is provided to assist the examiner in locating potentially relevant evidence. The examiner is asked to answer the following questions: (a.) Is the Veteran's obstructive sleep apnea caused by the service-connected chronic sinusitis and allergic rhinitis? Both of these disabilities should be considered in answering the question. Please explain upon what facts, medical principles, and/or medical literature the opinion is based. (b.) If the answer to (a.) is no, is the Veteran's obstructive sleep apnea was aggravated by the service-connected chronic sinusitis and allergic rhinitis? Aggravation is different than causation in that it did not cause the disability but rather caused an increase in the disability that is not due to the natural progress of the disability. Both of these disabilities should be considered in answering the question. Please explain upon what facts, medical principles, and/or medical literature the opinion is based. (c.) If the examiner finds that the service-connected chronic sinusitis and/or allergic rhinitis caused an increase in severity of the obstructive sleep apnea that is not due to the natural progress of the disability, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the obstructive sleep apnea prior to aggravation. If the examiner is unable to establish a baseline for the obstructive sleep apnea prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. The examiner is asked to provide a rationale for all conclusions reached with reference to relevant evidence of record and/or medical principles, as appropriate. If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Husain, 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.