FACIAL NERVE (VII CRANIAL NERVE) PARALYSIS

DAVID A. BRENNINGMEYER · 2026 · Case ID: 26004241

MIXED

Summary

The Veteran, an Army Veteran who served from August 1967 to August 1971, including service in Korea, appeals the denial of service connection for several polyneuropathy claims in his upper and lower extremities, and for cranial nerve impairment manifested by drooling. The Board granted service connection for cranial nerve impairment manifested by drooling, finding it secondary to the Veteran's service-connected myasthenia gravis, based on a favorable VA medical opinion. The Board found the September 2025 VA examiner's opinion to be the most probative evidence, citing its basis in examination, review of the claims file, medical literature, and a thorough rationale. The Board noted that the specific cranial nerve involved would be determined during the effectuation of the award. The claims for polyneuropathy in the upper and lower extremities, whether secondary to myasthenia gravis or due to herbicide exposure, were remanded. The Board found the Veteran has established polyneuropathy, supported by multiple EMG findings and statements, despite conflicting opinions from a September 2025 VA examiner. The remand instructions require an addendum opinion from the September 2025 examiner to address the polyneuropathy's secondary relationship to myasthenia gravis and/or herbicide exposure, considering all toxic exposures and relevant medical literature. The examiner must also address the polyneuropathy's relationship to myasthenia gravis, considering cited medical articles, and refrain from commenting on CTS or radiculopathy. The Board emphasized that the polyneuropathy diagnosis is distinct from CTS and radiculopathy.

Rationale

VA examination confirmed cranial nerve impairment manifested by drooling.; VA examiner provided positive nexus opinion linking drooling to service-connected myasthenia gravis.; Opinion based on examination, review of claims file, medical literature, and thorough rationale.

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

19-37 844

Full Decision Text

Citation Nr: 26004241
Decision Date: 04/07/26 Archive Date: 04/07/26

DOCKET NO. 19-37 844
DATE: April 7, 2026

ORDER

Service connection for cranial nerve impairment manifested by drooling is granted.

REMANDED

Entitlement to service connection for right upper extremity polyneuropathy, to include as due to exposure to herbicide agents and/or as secondary to myasthenia gravis, is remanded.

Entitlement to service connection for left upper extremity polyneuropathy, to include as due to exposure to herbicide agents and/or as secondary to myasthenia gravis, is remanded.

Entitlement to service connection for right lower extremity polyneuropathy, to include as due to exposure to herbicide agents and/or as secondary to myasthenia gravis, is remanded.

Entitlement to service connection for left lower extremity polyneuropathy, to include as due to exposure to herbicide agents and/or as secondary to myasthenia gravis, is remanded.

FINDING OF FACT

The Veteran has a cranial nerve impairment, manifested by drooling, that is at least as likely as not secondary to his service-connected myasthenia gravis.

CONCLUSION OF LAW

Resolving reasonable doubt in the Veteran's favor, the criteria for an award of service connection for cranial nerve impairment manifested by drooling have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty in the U.S. Army from August 1967 to August 1971, to include service in Korea.

This matter comes to the Board of Veterans' Appeals (Board) on appeal from an August 2017 rating decision issued by a Department of Veterans Affairs (VA) Regional Office.

In July 2021, the Veteran and his spouse testified at a virtual Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the record.

The issues currently on appeal were previously before the Board in January 2023 and November 2023, when they were remanded to the agency of original jurisdiction (AOJ) for additional development. The sole reason for the Board's remand was that the issues were inextricably intertwined with the Veteran's claim for service connection for myasthenia gravis, which was also remanded at that time and has since been granted.

On remand, the Veteran was afforded a VA examination, and medical opinions were obtained as to whether his upper and lower extremity polyneuropathies were secondary to his now service-connected myasthenia gravis. On review, the Board finds that the examination and opinions as to that question are inadequate. As such, further development is required. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (where VA provides a veteran with an examination, the examination must be adequate).

As noted, a claim for service connection for myasthenia gravis was previously on appeal, as were claims for service connection for residuals of removal of the thymus gland and for speech problems and droopy eyelids, all as secondary to myasthenia gravis. In a May 2025 rating decision, the AOJ granted service connection for myasthenia gravis, status post thymectomy, with left vocal cord paralysis; surgical scar, status/post thymectomy; and surgical scar, status/post thyroplasty implant. In an August 2025 rating decision, the AOJ granted service connection for eye/ocular residuals of myasthenia gravis. Inasmuch as the May 2025 and August 2025 rating decisions represent a full grant of the benefits sought on appeal with respect to service connection for myasthenia gravis, residuals of removal of the thymus gland, speech problems, and droopy eyelids, those issues are no longer on appeal before the Board. Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997).

By contrast, review of the record, to particularly include the rating decisions and codesheets, demonstrates that service connection has not been established for the symptom of drooling. As such, that issue remains pending on appeal. In that regard, a September 2025 VA examiner found that the Veteran's drooling was associated with impairment of either the 7th or 9th cranial nerve. The Board has recharacterized the issue accordingly, as set forth above.

Entitlement to service
the thymus gland, speech problems, and droopy eyelids, those issues are no longer on appeal before the Board. Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997).

Entitlement to service connection for drooling as secondary to service-connected myasthenia gravis

The Veteran contends that he experiences drooling secondary to his service-connected myasthenia gravis. As noted, based on the September 2025 VA examination findings, the Board finds that the disability is best characterized as cranial nerve impairment manifested by drooling.

Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a).

Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999).

Under applicable law, disability which is due to or the result of a service-connected disease or injury shall also be service connected. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show: (1) that a current disability exists; and (2) that the current disability was either (a) caused or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995).

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. An approximate balance of the evidence includes, but is not limited to, equipoise. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). Evidence is not in "approximate balance" or "nearly equal" when the evidence persuasively favors one side or the other. Id.

As noted previously, the Veteran was afforded a VA examination of the cranial nerves in September 2025. The examiner found that the Veteran experienced drooling (i.e., increased salivation) and droopy eyes, indicating that the nerves affected were the 7th and 9th cranial nerves. The examiner also offered a positive nexus opinion that the drooling was secondary to service-connected myasthenia gravis. The examiner reasoned that myasthenia gravis could cause drooling because the disease weakened the muscles responsible for chewing and swallowing. She added that drooling was a common symptom in people with myasthenia gravis who experienced weakness in their facial and throat muscles, which were affected by the autoimmune disorder. In support of her opinion, she cited to medical literature.

The Board finds that the September 2025 VA medical opinion is the most probative evidence of record as to whether the Veteran's drooling is secondary to his myasthenia gravis. The opinion was based on an examination of the Veteran and a complete review of the claims file, to include the Veteran's contentions, cited to medical literature, and was supported by a thorough rationale. As such, it is entitled to significant probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008) There are no contrary medical opinions of record.

The Board finds that an award of service connection for drooling as a manifestation of cranial nerve impairment is warranted. The September 2025 VA examination confirms the presence of a current disability, and the opinion indicates that it is at least as likely as not that the condition is secondary to the Veteran's service-connected myasthen
examination of the Veteran and a complete review of the claims file, to include the Veteran's contentions, cited to medical literature, and was supported by a thorough rationale. As such, it is entitled to significant probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008) There are no contrary medical opinions of record.

In arriving at this conclusion, the Board notes that the September 2025 VA examination report does not clearly distinguish which cranial nerve, the 7th or the 9th, is related to drooling. That determination will be made by the AOJ when the Board's award of service connection is effectuated.

REASONS FOR REMAND

1. Entitlement to service connection for right upper extremity polyneuropathy, to include as due to exposure to herbicide agents and/or as secondary to myasthenia gravis, is remanded.

2. Entitlement to service connection for left upper extremity polyneuropathy, to include as due to exposure to herbicide agents and/or as secondary to myasthenia gravis, is remanded.

3. Entitlement to service connection for right lower extremity polyneuropathy, to include as due to exposure to herbicide agents and/or as secondary to myasthenia gravis, is remanded.

4. Entitlement to service connection for left lower extremity polyneuropathy, to include as due to exposure to herbicide agents and/or as secondary to myasthenia gravis, is remanded.

The Veteran contends that the polyneuropathy in his upper and lower extremities is secondary to his now service-connected myasthenia gravis. The Board notes that the Veteran is already service-connected for radiculopathy of the lower extremities as secondary to service-connected intervertebral disc disease with degenerative arthritis of the lumbar spine (lumbar spine disability). Review of the claims file also shows that he has carpal tunnel syndrome (CTS) in the upper extremities.

While acknowledging that radiculopathy and CTS can cause symptoms similar to polyneuropathy, the Board notes that the Veteran is specifically not claiming service connection for CTS or for radiculopathy (the latter of which, in any event, is already service-connected). Rather, he is seeking service connection for the diagnosis of polyneuropathy in his extremities as secondary to myasthenia gravis. In support of his claim, in a January 2026 Post-Remand Brief, his representative cited to several medical articles and stated that they showed an unambiguous relationship between myasthenia gravis and polyneuropathy. In a November 2016 statement, an A.S.A., M.D., stated that according to medical literature, polyneuropathy had been linked to exposure to herbicide agents. The Board finds that the theory that the Veteran's polyneuropathy is due to his conceded in-service exposure to herbicide agents has therefore also been reasonably raised by the record.

As an initial matter, the Board notes that there is something of a conflict in the evidence as to whether the Veteran has polyneuropathy. EMG (electromyography) findings in March 2016 showed bilateral CTS as well as "probable underlying polyneuropathy." As noted, the Veteran submitted a statement from Dr. A. in November 2016. Dr. A. stated that the Veteran had been diagnosed with myasthenia gravis, polyneuropathy, and CTS. EMG findings in March 2020 showed severe mixed motor and sensory polyneuropathy and "probable underlying CTS." In the report of an August 2021 peripheral nerves examination that was afforded to the Veteran as part of a claim for increased ratings for radiculopathy, a VA examiner noted that the Veteran had an abnormal gait. The examiner noted further that the etiology of the abnormal gait was the Veteran's lumbar spine disability, but that he also had peroneal nerve neuropathy that was likely some form of polyneuropathy. By contrast, a September 2025 VA examiner found that the Veteran did not have a diagnosis of polyneuropathy. The examiner cited to 2017 neurological notes
findings in March 2020 showed severe mixed motor and sensory polyneuropathy and "probable underlying CTS." In the report of an August 2021 peripheral nerves examination that was afforded to the Veteran as part of a claim for increased ratings for radiculopathy, a VA examiner noted that the Veteran had an abnormal gait. The examiner noted further that the etiology of the abnormal gait was the Veteran's lumbar spine disability, but that he also had peroneal nerve neuropathy that was likely some form of polyneuropathy. By contrast, a September 2025 VA examiner found that the Veteran did not have a diagnosis of polyneuropathy. The examiner cited to 2017 neurological notes indicating that the Veteran had polyneuropathy, but then cited to the 2020 EMG findings, stating that those findings noted CTS, but that no diagnosis was given for polyneuropathy.

On review, the Board finds that the evidence supports a finding that the Veteran has polyneuropathy, as evidenced most clearly by the March 2020 EMG findings. That finding is consistent with the March 2016 EMG findings, Dr. A.'s November 2016 statement, and the November 2021 VA examiner's findings. Still further, it appears that the September 2025 VA examiner did not review the full results of the March 2020 EMG, which expressly note that the Veteran has severe mixed motor and sensory polyneuropathy. Her finding that the Veteran did not have polyneuropathy based on the March 2020 EMG finding is therefore inconsistent with the report itself and renders her examination report with respect to diagnosis inadequate.

In view of the foregoing, the Board finds that the first element of service connection, as to the presence of current disability, has been established. The primary question for the Board is whether the Veteran's polyneuropathy is secondary to his service-connected myasthenia gravis and/or due to his conceded in-service exposure to herbicide agents.

As noted, in his November 2016 statement, Dr. A. stated that according to medical literature, polyneuropathy had been linked directly to exposure to herbicide agents.

While supportive of the Veteran's claim, the Board finds Dr. A.'s November 2016 statement insufficient for an award of service connection. Dr. A. did not cite to any medical literature or otherwise provide any rationale to support his opinion.

As noted, the Veteran was afforded a VA examination in connection with his claim in September 2025. The examiner found that the Veteran had CTS and lower extremity radiculopathy, but that he did not have polyneuropathy. On examination, she indicated that the Veteran's gait was abnormal and indicated that the etiology of the abnormal gait was "polyneuropathy and back condition." She then cited to the 2016 EMG showing CTS and probable underlying polyneuropathy, but under remarks stated that there was no diagnosis of polyneuropathy. She noted further that the Veteran was already service-connected for radiculopathy, and that it was unrelated to the claimed condition of myasthenia gravis.

The examiner then offered a negative nexus opinion as to whether the Veteran's CTS was secondary to his service-connected myasthenia gravis. She also offered a negative nexus opinion as to whether the Veteran's CTS was due to his conceded participation in toxic exposure risk activity (in this case, in-service exposure to herbicide agents). While the examiner addressed polyneuropathy in the remarks section of the report, she opined that medical literature did not support a relationship between myasthenia gravis and polyneuropathy, but that there was no diagnosis of polyneuropathy, and that a nexus was therefore not established.

The Board finds that the September 2025 VA examination and opinion are inadequate. The examination is inadequate because, as noted, the examiner failed to note a diagnosis of polyneuropathy, even where EMG testing in 2016 was suggestive of polyneuropathy and EMG testing in 2020 confirmed that the Veteran had polyneuropathy in addition to CTS. The examination report is also somewhat internally inconsistent in that the examiner found that the Veteran did not have polyneuropathy but also attributed the Veteran's abnormal gait, in part, to polyneuropathy. The opinions as to secondary service connection and as to whether polyneuropathy is due to in-service exposure to herbicide agents are inadequate because they do not answer the question being asked. The examiner offered negative nexus opinions as to CTS, a condition which is not being claimed. The opinion the examiner did appear to offer as to poly
G testing in 2016 was suggestive of polyneuropathy and EMG testing in 2020 confirmed that the Veteran had polyneuropathy in addition to CTS. The examination report is also somewhat internally inconsistent in that the examiner found that the Veteran did not have polyneuropathy but also attributed the Veteran's abnormal gait, in part, to polyneuropathy. The opinions as to secondary service connection and as to whether polyneuropathy is due to in-service exposure to herbicide agents are inadequate because they do not answer the question being asked. The examiner offered negative nexus opinions as to CTS, a condition which is not being claimed. The opinion the examiner did appear to offer as to polyneuropathy in the remarks section of her opinion report is also inadequate, as it based on the inaccurate factual premise that the Veteran does not have polyneuropathy. Finally, inasmuch as the medical articles which purport to show an association between myasthenia gravis and polyneuropathy were not submitted by the Veteran until January 2026, the examiner was unable to consider them. Under the circumstances, a remand for an addendum medical opinion is required. Updated records of VA treatment should also be procured.

These matters are REMANDED for the following action:

1. Obtain copies of records pertaining to any VA treatment the Veteran has received since the time that such records were last procured, following the procedures set forth in 38 C.F.R. § 3.159. The evidence obtained, if any, should be associated with the record.

2. After the foregoing development has been completed, arrange to provide the record on appeal to the VA examiner who examined the Veteran and offered an opinion as to the etiology of his polyneuropathy in September 2025.

The Board emphasizes that the presence of a current disability of polyneuropathy has been established, as evidenced by a March 2020 EMG report showing severe mixed motor and sensory polyneuropathy.

After reviewing the record, the examiner should offer an addendum opinion as to whether it is at least as likely as not (i.e., whether the likelihood is at least approximately balanced, or nearly equal, if not higher), that the Veteran's diagnosed polyneuropathy was caused by his participation in toxic exposure risk activity during service (in this case, his conceded in-service exposure to herbicide agents and any other confirmed in-service toxic exposures). In addressing that question, the examiner must consider (a) the total potential exposure through all applicable military deployments of the Veteran, and (b) the synergistic, combined effect of all toxic exposure risk activities of the Veteran.

In formulating her response, the examiner should also consider and address Dr. A.'s November 2016 statement.

If the examiner finds that it is unlikely that the Veteran's polyneuropathy was caused by his participation in toxic exposure risk activity during service, she should offer a further opinion as to whether it is at least as likely as not that the condition (a) was caused or (b) has been aggravated by his service-connected myasthenia gravis.

In so doing, the examiner should consider and address the medical articles cited by the Veteran's representative as to an association between polyneuropathy and myasthenia gravis in the January 2026 Post-Remand Brief.

In proffering these opinions, the examiner should refrain from offering opinions as to the etiology of CTS and/or lower extremity radiculopathy. The Veteran is not claiming service connection for CTS, and he is already service connected for lower extremity radiculopathy. The Board emphasizes that it is seeking an opinion as to the etiology of the Veteran's polyneuropathy, a diagnosis that has been established on the record to be distinct and separate from CTS and/or lower extremity radiculopathy.

If the September 2025 VA examiner is no longer employed by VA, or is otherwise unable to provide the requested opinion, arrange to obtain the requested information from another qualified examiner. The need for another in-person examination, or video or telephone interview of the Veteran is left to the discretion of the examiner.

A complete medical rationale for all opinions expressed must be provided.

3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the issues remaining on appeal should be readjudicated based on the entirety of the evidence. If any benefit sought remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response.

DAVID A. BRENNINGMEYER

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the

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