SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

VITO A. CLEMENTI · 2025 · Case ID: 25000348

DENIED

Summary

The Veteran, who served in the U.S. Navy from February 1992 to August 1994, appeals the denial of service connection for obstructive sleep apnea (OSA), including a secondary claim based on his service-connected allergic rhinitis. The Veteran was diagnosed with severe OSA in 2006, with a high apnea-hypopnea index (AHI) of 37.1, and contends the condition was caused or aggravated by his allergic rhinitis. The Board reviewed the Veteran's service treatment records, which did not mention OSA or sleep disordered breathing. Post-service records indicated OSA improved with weight loss, with a later sleep study showing a mild AHI of 7.7 in 2023. While earlier VA examinations noted potential links between rhinitis and OSA, a comprehensive March 2024 VA examination and CT scan found no structural abnormalities in the Veteran's airway that would support a causal link between his rhinitis and OSA. The March 2024 examiner opined that obesity was the primary factor in the Veteran's OSA and that his rhinitis did not cause or aggravate the condition, citing conflicting medical literature and the lack of corroborating findings in recent examinations. The Board found this opinion highly persuasive due to its thoroughness, reliance on medical literature, and the Veteran's improved OSA symptoms with weight loss, outweighing earlier, less detailed opinions. Direct service connection was denied due to lack of in-service manifestation or cause, and secondary connection was denied as the evidence did not establish that service-connected rhinitis caused or aggravated the OSA.

Rationale

Service treatment records do not show OSA or sleep disordered breathing.; Post-service records indicate OSA improved with weight loss.; March 2024 VA opinion found obesity primary factor, no structural causes for OSA from rhinitis.; March 2024 VA opinion opined rhinitis did not cause or aggravate OSA, citing conflicting literature and lack of corroborating findings.; Direct service connection denied due to lack of in-service manifestation or cause.

Service Branch

NAVY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

17-01 747

Full Decision Text

Citation Nr: 25000348
Decision Date: 01/10/25 Archive Date: 01/10/25

DOCKET NO. 17-01 747
DATE: January 10, 2025

ORDER

Service connection for obstructive sleep apnea (OSA), including secondary to service-connected allergic rhinitis, is denied.

FINDING OF FACT

The Veteran's OSA was not caused by any incident of service and was not caused or aggravated beyond its baseline by his service-connected allergic rhinitis.

CONCLUSION OF LAW

The criteria to establish service connection for OSA, including secondary to service-connected allergic rhinitis, have not been met. 38 U.S.C. §§ 1101, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.304, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran had active service in the U.S. Navy from February 1992 to August 1994.

In June 2023, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ). During the hearing, the VLJ engaged in a discussion with the Veteran towards substantiating the claims. Bryant v. Shinseki, 23 Vet. App. 488 (2010). The transcript is in the record.

In January 2024, the Board of Veterans' Appeals (Board) remanded the claim to a VA Regional Office (RO) to obtain a medical examination and opinion, which were completed in March 2024. The RO complied with the Board's remand instructions. Stegall v. West, 11 Vet. App. 268 (1998).

SERVICE CONNECTION

VA grants service connection for disabilities 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). "Direct" service connection requires: (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus (a causal link) between the current disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Disorders diagnosed after discharge may still be service connected if the evidence establishes that the disorder was incurred in service. 38 C.F.R. § 3.303 (d); see Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994).

A veteran may establish service connection on a "secondary" basis for a non- service-connected disability that was caused by a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310 (b). See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc).

A finding of aggravation requires that a baseline level of severity for the claimed disability is established with evidence created prior to any aggravation, or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence stablishing the current level of severity of the disability. 38 C.F.R. § 3.310 (b).

While obesity is not capable of being service-connected, it may be an "intermediate step" between a service-connected disability and a current disability for which service connection may be granted on a secondary basis under 38 C.F.R. § 3.310 (a). See Walsh v. Wilkie, 32 Vet. App. 300 (2020) (holding that obesity as an "intermediate step" in a causal chain for service connection can be established on either a causal or aggravation basis).

When the Board evaluates a claim, it must decide if the evidence is competent. "Competent" evidence comes from a person who is qualified to make a statement or opinion because of their training, education, or experience.

For example, medical professionals are generally competent through training and experience to diagnose medical conditions and express opinions about whether a disability was caused by service. Generally, the opinions of medical professionals such as doctors, psychiatrists, nurses, and others who work in the health care field may be competent because they apparently have specialized training, as shown in the detail
. 300 (2020) (holding that obesity as an "intermediate step" in a causal chain for service connection can be established on either a causal or aggravation basis).

For example, medical professionals are generally competent through training and experience to diagnose medical conditions and express opinions about whether a disability was caused by service. Generally, the opinions of medical professionals such as doctors, psychiatrists, nurses, and others who work in the health care field may be competent because they apparently have specialized training, as shown in the detail of their reports and knowledge of the facts in individual cases.

A person without medical training (i.e., a "layperson") is generally not competent to diagnose complex medical conditions or give an opinion on the cause of a disease or injury. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). For example, a layperson would not be competent to diagnose cancer or give an opinion that cancer was caused by an event during military service.

However, a layperson is competent to report symptoms that they observe firsthand through their senses. For example, a layperson does not need medical training to competently state that they have ringing in the ears, pain, a limp, a broken leg, difficulty breathing, or skin rashes. See Jandreau, Barr v. Nicholson, 21 Vet. App. 303 (2007).

In deciding claims, the Board evaluates the entire record on appeal. 38 U.S.C. § 7104 (a). When the evidence fully supports the claim, it will be granted. When the evidence for and against the claim is approximately balanced, the Board resolves any reasonable doubt in the Veteran's favor and grant the claim. When the evidence is not approximately balanced, there is no reasonable doubt to resolve, and the claim will be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 999 F.3rd 1391 (2021).

Service connection for OSA, including secondary to service-connected allergic rhinitis, is denied.

The Veteran was diagnosed with OSA in a 2006 sleep study and contends the condition was caused or aggravated by his service-connected allergic rhinitis.

The claim will be denied for the reasons below.

OSA is the "cessation of breathing resulting from the collapse or obstruction of the airway with the inhibition of muscle tone that occurs during REM sleep." See Dorland's Illustrated Medical Dictionary 116-17 (32nd ed. 2012).

This decision will focus solely on the Veteran's OSA symptoms and not sleep disturbances from his nonservice-connected psychiatric disorder.

The Veteran's service treatment records (STRs) do not show OSA or sleep disordered breathing.

In a March 1993 health questionnaire, the Veteran endorsed a history of coughing, "scratchy throat," and sinus problems.

In November 1993, the Veteran endorsed nasal congestion and a history of "sinus problems." X-rays taken in November 1993 showed normal paranasal sinuses without evidence of mucosal thickening or bone destruction.

The Veteran's post-service medical records show that his OSA improved from 2006 to 2023 after losing weight. His medical providers consistently noted obesity as a contributing factor to OSA and routinely advised the Veteran to lose weight.

The Veteran was diagnosed with "severe" OSA at a February 2006 non-VA sleep study. His apnea-hypopnea index (AHI) was 37.1 and he weighed 258 pounds.

As a definitional usage, the Board notes that the AHI measures the severity of sleep apnea and is represented by an average number of apnea and hypopnea episodes per hour during sleep. See https://www.hopkinsmedicine.org/health/conditions-and-diseases/obstructive-sleep-apnea; see also Smith v. Derwinski, 1 Vet. App. 235, 238 (1991) ("Courts may take judicial notice of facts not subject to reasonable dispute" (citing FED. R. EVID. 201 (b))).

At a February 2006 sleep medicine consultation, the Veteran reported he did not know when his sleep problems began. He weighed 255 pounds. The Veteran reported he was then regularly taking Mucinex for a respiratory infection. The attending clinician noted obesity and hypertension were comor
nea and hypopnea episodes per hour during sleep. See https://www.hopkinsmedicine.org/health/conditions-and-diseases/obstructive-sleep-apnea; see also Smith v. Derwinski, 1 Vet. App. 235, 238 (1991) ("Courts may take judicial notice of facts not subject to reasonable dispute" (citing FED. R. EVID. 201 (b))).

The "Mallampati Score" is a method of assessing the size and shape of a patient's tongue and esophageal airway. See https://www.sleepfoundation.org/sleep-apnea/mallampati-score; see also Smith, above.

At a follow-up later in February 2006, the Veteran reported he had not used his continuous positive airway pressure machine ("CPAP") for two days because of a respiratory infection. However, he reported "good results" when using the CPAP.

In June 2007, a non-VA clinician opined that the Veteran's OSA was "stable." The Veteran weighed 244 pounds.

In February 2008, the Veteran reported regularly using his CPAP and denied frequent awakenings, trouble falling asleep, or congestion while using the CPAP.

At a July 2010 VA mental disorders examination, the Veteran endorsed trouble sleeping and night sweats for the past five years. He reported he was diagnosed with OSA in 2005 and that the condition did not cause any disability.

At an April 2011 VA respiratory disorders examination, the Veteran endorsed sinus problems and difficulty breathing through his nose since 1993. He reported his response to using a CPAP was "good" and denied any "side effects." The Veteran denied having any "overall functional impairment" from his OSA and rhinitis.

The April 2011 VA examiner opined that, generally, persistent allergic rhinitis "will lead to chronic irritation and enlargement of tissues in [the] posterior pharynx, predisposing one to OSA." However, on physical examination in April 2011, the clinician found no evidence of nasal obstruction, deviated septum, nasal polyps, rhinitis, or sinusitis. The clinician opined that the Veteran's chest, lungs, and breathing sounds were normal.

In August 2014, the Veteran endorsed sinus congestion and coughing. A VA clinician opined that the Veteran's throat was "mildly reddened" but showed no sign of infection or other abnormalities. The clinician noted that the Veteran frequently used strong body oils/cologne and advised him that these substances were aggravating his sinus problems.

In September 2014, the Veteran endorsed sinus congestion, snoring, apneas, awakening choking or gasping for breath, and restless and unrefreshing sleep. A home sleep study later that month indicated an AHI of 7.7. He weighed 266 pounds.

At a February 2017 VA sinusitis/rhinitis/pharynx conditions examination, the Veteran endorsed worsening congestion and nasal drainage and that he could not use his CPAP when his nose was irritated.

The Veteran was treated for nonservice-connected viral pharyngitis (herpes) at a VA emergency room in August 2017. The attending clinician noted Mallampati airway Class III.

At a February 2019 VA sinusitis/rhinitis/pharynx conditions examination, a clinician noted permanent hypertrophy of the nasal turbinates and greater than 50 percent obstruction of the nasal passage on both sides due to rhinitis. However, the VA examiner noted that no imaging studies of the sinuses or other areas had been performed.

In March 2020, a VA clinician opined that the Veteran's obesity was the most significant factor in his developing OSA and noted his BMI was 30 when he was diagnosed with OSA in 2006. The clinician opined that obesity is associated with upper airway obstruction by increasing neck circumference, which may lead to airflow obstruction.

The March 2020 VA examiner opined that the Veteran's OSA was not aggravated by his service-connected rhinitis because his OSA was "mild" and there was no evidence that the condition worsened. The clinician further opined that there was no evidence showing treatment for unstable allergic rhinitis or an airway obstruction.

In September 2020, a VA clinician opined that the Veteran's airway
ined that the Veteran's obesity was the most significant factor in his developing OSA and noted his BMI was 30 when he was diagnosed with OSA in 2006. The clinician opined that obesity is associated with upper airway obstruction by increasing neck circumference, which may lead to airflow obstruction.

In September 2020, a VA clinician opined that the Veteran's airway was "within normal limits."

The Veteran had a LAP band removed and replaced with a gastric sleeve in December 2020/January 2021.

Later in January 2021, the Veteran reported that he weighed 188 pounds and had lost 40 pounds since February 2020.

In June 2022, the Veteran endorsed sleep interruptions due to "violent, recurring dreams," and anxiety/stress related to his nonservice-connected psychiatric disorder. He reported difficulty using his CPAP because of these symptoms.

In August 2022, the Veteran reported his sleep improved when taking an antidepressant (Doxepin). He stated he was using a CPAP but still waking up in the middle of the night, although not as often.

Later in August 2022, the Veteran reported "sleeping well" "most nights."

In December 2022, the Veteran reported sleep interruptions on "some nights." He reported using a CPAP but "ha[d] not followed up in years."

At his June 2023 Board hearing, the Veteran reported losing 50 pounds since 2017 but still had frequent nighttime awakenings and sleep apnea. The Veteran indicated that no medical provider had linked his OSA with his allergic rhinitis.

A February 2024 facial CT scan showed "mild" mucosal thickening in the nasal cavities and right maxillary and ethmoid sinuses, but clear paranasal sinuses. The scan did not show any soft tissue or bony abnormalities.

In March 2024, a VA clinician noted medical literature suggesting an increased prevalence of OSA among patients with allergic rhinitis, but opined there was no literature showing that rhinitis causes OSA. The clinician reviewed the February 2024 facial CT scan and opined that it did not show any structural causes of OSA (e.g., abnormal maxillary or short mandibular size, wide craniofacial base, or tonsillar and adenoid hypertrophy). The clinician further opined that the February 2024 CT findings (see above) may cause rhinitis, they would not cause OSA. Additionally, the clinician opined that the 2024 CT scan did not show turbinate hypertrophy noted at the February 2019 VA sinusitis/rhinitis/pharynx conditions examination (see above).

The March 2024 VA clinician opined that the Veteran's OSA was not aggravated by his rhinitis because his OSA "significantly improved." The clinician noted that the Veteran's OSA was "severe" in 2006 (37.1 AHI), but "mild" in 2023 (5.8 AHI). The clinician opined that the Veteran's OSA improved because of weight loss and cited medical literature showing that weight loss of just 10-15% can reduce the severity of OSA by 50% in moderately obese patients. However, the clinician opined that weight loss does not "cure" OSA.

The March 2024 clinician opined that, generally, allergic rhinitis may aggravate CPAP tolerance, but noted that the Veteran's medical records showed he tolerated his CPAP "well."

The March 2024 VA opinion is highly persuasive because it was based on the Veteran's medical history, the examiner's medical expertise, and relevant medical literature. The examiner gave a fully articulated explanation for her conclusions, and her opinion is highly probative. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion depends upon whether it is factually accurate, fully articulated, and contains sound reasoning for the conclusion).

The evidence outlined above weighs heavily against finding that the Veteran's OSA was caused or aggravated by his service-connected allergic rhinitis.

The March 2024 examiner thoroughly explained that obesity was the primary factor causing the Veteran's OSA and that he does not have other structural risk factors. Importantly, the examiner opined that losing weight can reduce OSA symptoms (as
medical literature. The examiner gave a fully articulated explanation for her conclusions, and her opinion is highly probative. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion depends upon whether it is factually accurate, fully articulated, and contains sound reasoning for the conclusion).

The evidence outlined above weighs heavily against finding that the Veteran's OSA was caused or aggravated by his service-connected allergic rhinitis.

As a layperson, the Veteran is not competent to opine that his OSA was caused or aggravated by his service-connected allergic rhinitis. Jandreau, above. His contentions are substantially outweighed by the March 2024 VA opinion.

The Board considered the April 2011 VA examiner's opinion that rhinitis "will lead to chronic irritation and enlargement of tissues in [the] posterior pharynx, predisposing one to OSA," and the February 2019 VA sinus examination report noting permanent hypertrophy of the nasal turbinates and greater than 50 percent obstruction of the nasal passage on both sides.

However, the March 2024 examiner opined that physical examinations and CT scans during the appeal have not shown findings of rhinitis or sinusitis (including hypertrophy of nasal turbinates), or other "structural abnormality or enlargement" suggesting that rhinitis could have caused the Veteran's OSA. The March 2024 examiner specifically opined that the April 2011 and February 2019 examiner's findings were not corroborated by the record.

The March 2024 VA opinion is more persuasive than the April 2011 and February 2019 examiners' opinions because it is supported by a thorough review of relevant medical literature and the Veteran's history, including diagnostic testing. In contrast, the April 2011 and February 2019 examiners did not cite medical literature or supporting facts in the Veteran's medical records. See Owens v. Brown, 7 Vet. App. 429 (1995) (The Board may favor one medical opinion over another if its reasons and bases are adequate to support that decision.).

Additionally, the evidence weighs heavily against finding that the Veteran's OSA was aggravated beyond its baseline by service-connected allergic rhinitis.

When the Veteran was diagnosed with OSA in 2006, his AHI was 37.1 and he was prescribed a CPAP. These symptoms would equate to a 50 percent rating under VA's Schedule for Rating Disabilities. See 38 C.F.R. § 4.97; Diagnostic Code 6847 (A 50 percent rating is assigned for OSA that requires use of breathing assistance device such as a CPAP machine). The next higher rating (100 percent) for OSA requires chronic respiratory failure with carbon dioxide retention or cor pulmonale, or; tracheostomy. Id.

The Veteran used a CPAP machine throughout the appeal but reported improvement in OSA symptoms after losing weight. Even considering the instances where the Veteran reported difficulty using his CPAP due to congestion, the March 2024 VA examiner opined that the Veteran's OSA improved, as evidenced by consistently lower AHI (5.8 in 2023). Accordingly, the evidence weighs against finding that the Veteran's OSA worsened beyond its baseline by his rhinitis.

There is no persuasive evidence that the Veterans' Class II Mallampati score in February 2006 and Class III score in August 2017 were caused by his rhinitis or represent worsening OSA due to rhinitis. The Mallampati score taken in August 2017 was related to the Veteran's treatment for nonservice-connected pharyngitis. Additionally, the March 2024 VA examiner cited medical literature suggesting that "researchers have reported conflicting results about the efficacy of using Mallampati scoring to predict OSA."

Direct service connection is not warranted because there is no evidence or allegation that the Veteran's OSA manifested during active service or was caused by any incident of service.

Secondary service connection based on obesity as an intermediate step is not warranted because there is no evidence or allegation that the Veteran's service-connected disabilities caused him to become obese or aggravated his obesity. See Walsh, above.

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For the reasons above, the persuasive evidence weighs heavily against the claim and is not approximately balanced. There is no reasonable doubt to resolve and the claim is denied. Lynch, above.

Vito
VA examiner cited medical literature suggesting that "researchers have reported conflicting results about the efficacy of using Mallampati scoring to predict OSA."

Direct service connection is not warranted because there is no evidence or allegation that the Veteran's OSA manifested during active service or was caused by any incident of service.

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For the reasons above, the persuasive evidence weighs heavily against the claim and is not approximately balanced. There is no reasonable doubt to resolve and the claim is denied. Lynch, above.

Vito A. Clementi

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board B. Hiaasen

The Board's action is only binding on this case. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.

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