FACIAL NERVE (VII CRANIAL NERVE) PARALYSIS

Summary

The Veteran served on active duty from February 1980 to June 1992. The Veteran appeals the denial of service connection for a voice disability (dysphonia) and a lung disability (right diaphragmatic paralysis and compressive atelectasis), claiming both are secondary to a service-connected left leg amputation due to varicose veins, with a tracheostomy and prolonged intubation/ventilatory support acting as intermediate factors. The Veteran's lay statements indicated voice loss and dyspnea on exertion, attributing these to the service-connected amputation. Service treatment records were silent for both conditions. The VA examiner opined that the dysphonia and lung disability were not related to military service, but acknowledged the dysphonia was likely secondary to tracheostomy-related trauma and the lung disability was a result of prolonged intubation/tracheostomy, not the amputation itself. The Board found the VA examiner's opinion inadequate for both conditions, noting the examiner acknowledged a causal link to complications from the amputation (tracheostomy/intubation) but then denied service connection based on the amputation itself. The Board found the evidence in approximate balance for both claims, applying the benefit of the doubt to grant service connection for dysphonia and for right diaphragmatic paralysis and compressive atelectasis, both secondary to the service-connected left leg amputation with the specified intermediate factors. Service connection for both conditions was granted.

Rationale

VA examiner noted dysphonia likely secondary to tracheostomy-related trauma; Examiner's opinion found inadequate as it denied service connection despite acknowledging intermediate factor; Evidence in approximate balance, benefit of doubt applied

Full Decision Text

Citation Nr: A26031757
Decision Date: 04/07/26	Archive Date: 04/07/26

DOCKET NO. 260121-626542
DATE: April 7, 2026

ORDER

Entitlement to service connection for a voice disability, diagnosed as dysphonia, to include as secondary to service-connected left leg amputation associated with a left lower extremity varicose veins disability with a tracheostomy acting as a significant intermediate factor, is granted.

Entitlement to service connection for a lung disability, diagnosed as right diaphragmatic paralysis and compressive atelectasis, to include as secondary to service-connected left leg amputation associated with a left lower extremity varicose veins disability with prolonged intubation and ventilatory support acting as a significant intermediate factor, is granted.

FINDINGS OF FACT

1. The Veteran's dysphonia has been adequately related to service-connected disability.  

2. The Veteran's right diaphragmatic paralysis and compressive atelectasis has been adequately related to service-connected disability.  

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for dysphonia, to include as secondary to service-connected left leg amputation associated with a left lower extremity varicose veins disability with a tracheostomy acting as a significant intermediate factor, have been met.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310, 4.3.

2. The criteria for entitlement to service connection for right diaphragmatic paralysis and compressive atelectasis, to include as secondary to service-connected left leg amputation associated with a left lower extremity varicose veins disability with prolonged intubation and ventilatory support acting as a significant intermediate factor, have been met.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310, 4.3.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from February 1980 to June 1992.

The rating decision on appeal were issued in August and November 2025 after which the Veteran filed a January 2026, VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement); the Veteran elected the Direct Review docket. 

Direct review is the appeal option to the Board in which a Board decision is issued based on evidence of record at the time of the prior decision.  The Board cannot hold a Board hearing or accept into the record additional evidence in its direct review. 

The Board has broadened the issue on appeal to include entitlement to service connection for any voice related disorders and any lung related disorders.  

The Board has recharacterized the Veteran's claims as entitlement to service connection for a voice disability, diagnosed as dysphonia, to include as secondary to service-connected left leg amputation associated with a left lower extremity varicose veins disability with a tracheostomy acting as a significant intermediate factor and entitlement to service connection for a lung disability, diagnosed as right diaphragmatic paralysis and compressive atelectasis, to include as secondary to service-connected left leg amputation associated with a left lower extremity varicose veins disability with prolonged intubation and ventilatory support acting as a significant intermediate factor, to accurately depict the full scope of his disability claim.  Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009).

Service Connection

The Veteran contends that his disabilities are related to his military service.

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service.  38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303.  Service connection may also be granted for any disease diagnosed after discharge from service when all of the evidence, including lay evidence, establishes that the disability is due to disease or injury which was incurred in or aggravated by service.  38 C.F.R. § 3.303(d).

In order to establish service connection for a claimed disability, the following three elements must be satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship nexus) between the present disability and the disease or injury incurred or aggravated during service.  Hickson v. West, 12 Vet. App. 246 (1999).

Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability
 evidence, including lay evidence, establishes that the disability is due to disease or injury which was incurred in or aggravated by service.  38 C.F.R. § 3.303(d).

In order to establish service connection for a claimed disability, the following three elements must be satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship nexus) between the present disability and the disease or injury incurred or aggravated during service.  Hickson v. West, 12 Vet. App. 246 (1999).

Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability.  See 38 C.F.R. § 3.310(a).  When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition.  See 38 C.F.R. § 3.310(a); Harder v. Brown, 5 Vet. App. 183, 187 (1993).  The governing regulation has been interpreted to permit a grant of service connection not only for a disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability.  Allen v. Brown, 7 Vet. App. 439, 448 (1995).

In Ward v. Wilkie, the United States Court of Appeals for Veterans Claims held that, for secondary service connection, "aggravation" need not be permanent in nature.  31 Vet. App. 233, 241-42 (2019).

Recently, the United States Court of Appeals for the Federal Circuit decided Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023).  In Spicer, the United States Court of Appeals for the Federal Circuit held that secondary service connection under 38 U.S.C. § 1110 is warranted for any increase in a nonservice-connected disability that is due to a service-connected disability, including where a service-connected disability precludes treatment for a nonservice-connected disability.  Id. at 1363-1365.  That decision also found unlawful the VA regulation that required evidence establishing a pre-aggravation baseline before secondary service connection based on aggravation could be granted.  Id. at 1366 ("We decide this case based on our interpretation of § 1110 alone.  To the extent that the VA also applied 38 C.F.R. § 3.310(b) to reject Mr. Spicer's theory of compensation, that regulation is unlawful as inconsistent with 38 U.S.C. § 1110.").

Although obesity itself is not considered a disability for VA purposes, when obesity has been caused by a service-connected condition, and subsequently causes another disability, obesity may be considered an "intermediate step" for establishing service connection on a secondary basis.  See VAOPGCPREC 1-2017 (January 6, 2017).

In Walsh v. Wilkie, 32 Vet. App. 300, the United States Court of Appeals for Veterans Claims (the Court) held that when addressing the question of obesity as an intermediate factor, VA must evaluate whether a service-connected disability caused or aggravated the Veteran's obesity, just as it would when analyzing secondary service connection under 38 C.F.R. § 3.310.

In evaluating the evidence in an appeal, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in doing so, accept certain medical opinions over others.  Schoolman v. West, 12 Vet. App. 307 (1999).  In this regard, the Board has been charged with the duty to assess the credibility and weight given to the evidence.  Jandreau v. Nicholson, 492 F.3d 1372 (2007).

Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file.  See Prejean v. West, 13 Vet. App. 444, 448-449 (2000).  Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, and a basis in objective supporting clinical data.  See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998).  In concluding that no relationship between a current disability and military service exists, the examiner may not rely solely on an absence of medical
 takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file.  See Prejean v. West, 13 Vet. App. 444, 448-449 (2000).  Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, and a basis in objective supporting clinical data.  See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998).  In concluding that no relationship between a current disability and military service exists, the examiner may not rely solely on an absence of medical records and not consider any available competent and credible lay statements.  Dalton v. Nicholson, 21 Vet. App. 23 (2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336-1336 (2006).

In adjudicating a claim of service connection, the Board is required to evaluate evidence based on places, types, and circumstances of service, as shown by the veteran's military records and all pertinent medical and lay evidence.  Hayes v. Brown, 5 Vet. App. 60, 66 (1993); see also 38 U.S.C. § 1154(a).

When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant.  38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102.  When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in approximate balance, with the veteran prevailing in either event.  38 U.S.C. § 5107(b); Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021); Gilbert v. Derwinski, 1 Vet. App. 49 (1990).

Entitlement to service connection for a voice disability, diagnosed as dysphonia, to include as secondary to service-connected left leg amputation associated with left lower extremity varicose veins disability with a tracheostomy acting as a significant intermediate factor, is granted

As to a current diagnosis, the Board notes that the Veteran's disorder has been diagnosed as dysphonia.  See June 2025 VA examination. 

As to the Veteran's lay statements, the Veteran stated that his voice disability is a result of left lower extremity varicose vein disorder while in service.  The Veteran noted that he experiences voice loss and chronic vocal changes.

As to the in-service incurrence, the Board notes that the Veteran's service treatment records are silent for any treatment or a diagnosis for a voice disorder.  

Turning to the medical evidence at hand, the Board notes that the Veteran attended a VA examination for this issue in June 2025.  The Veteran reported that he experiences persistent hoarseness, vocal fatigue, and increased effort during speech production, resulting in the need to "place more force" when speaking.  The examiner noted that the Veteran has persistent voice impairment, likely secondary to scarring or vocal cord dysfunction post-intubation/tracheostomy.  The examiner opined that the Veteran's disability as secondary to a left leg amputation due to a left lower extremity varicose vein disability was not related to his military service.  However, the examiner concluded in the opinion that the Veteran's vocal disability is the "result of an intervening medical complication (i.e., tracheostomy-related trauma) rather than a direct physiological outcome of the amputation or vascular condition."  The examiner further noted that "otolaryngologic and critical care literature indicating that tracheostomy-related dysphonia is caused by airway trauma rather than distal vascular or orthopedic pathology."

The Board finds the VA examiner's opinion inadequate.  The Board reached this conclusion because the examiner simply found that the Veteran's disorder was not related to his military service because there was not a secondary service connection between the Veteran's left leg amputation due to a left lower extremity varicose vein disability and his voice disorder.  However, the Board notes that the examiner concluded that the Veteran's dysphonia disability was causally related to a "tracheostomy" that was a complication of the left leg amputation, which then acted as a significant intermediate factor.

Based on review of the record, both lay and medical, the Board finds that the evidence is at least in relative equipoise as to whether the Veteran's diagnosed dysphonia, to include as secondary to service-connected left leg amputation associated with a left lower extremity varicose
 Veteran's disorder was not related to his military service because there was not a secondary service connection between the Veteran's left leg amputation due to a left lower extremity varicose vein disability and his voice disorder.  However, the Board notes that the examiner concluded that the Veteran's dysphonia disability was causally related to a "tracheostomy" that was a complication of the left leg amputation, which then acted as a significant intermediate factor.

Based on review of the record, both lay and medical, the Board finds that the evidence is at least in relative equipoise as to whether the Veteran's diagnosed dysphonia, to include as secondary to service-connected left leg amputation associated with a left lower extremity varicose veins disability with a tracheostomy acting as a significant intermediate factor is related to service.  The most probative opinions of record, the June 2025 VA examination conclusion weighing in favor of the claim "with a tracheostomy acting as a significant intermediate factor" and the June 2025 VA examination opinion weighing against the claim are equally probative.  In other words, the Board finds that the positive and negative evidence of record is in approximate balance.  Accordingly, the Board resolves any reasonable doubt in the appellant's favor and finds that entitlement to service connection for dysphonia, to include as secondary to service-connected left leg amputation associated with a left lower extremity varicose veins disability with a tracheostomy acting as a significant intermediate factor, is therefore warranted.  38 U.S.C. § 5107; 38 C.F.R. § 3.102.  

Entitlement to service connection for a lung disability, diagnosed as right diaphragmatic paralysis and compressive atelectasis, to include as secondary to service-connected left leg amputation associated with left lower extremity varicose veins disability with prolonged intubation and ventilatory support acting as a significant intermediate factor, is granted.

As to a current diagnosis, the Board notes that the Veteran's disorder has been diagnosed as right diaphragmatic paralysis and compressive atelectasis.  See June 2025 VA examination. 

As to the Veteran's lay statements, the Veteran stated that his lung disability is a result of left lower extremity varicose vein disorder while in service.  The Veteran noted that he experiences dyspnea on exertion and limited ventilatory capacity.

As to the in-service incurrence, the Board notes that the Veteran's service treatment records are silent for any treatment or a diagnosis for a lung disorder.  

Turning to the medical evidence at hand, the Board notes that the Veteran attended a VA examination for this issue in June 2025.  The Veteran reported at this time that he experiences persistent dyspnea on exertion and fatigue with minimal activity, resulting in the reliance on accessory muscles for ventilation and decreased chest wall expansion. The examiner noted that the Veteran has respiratory limitations that significantly impair his ability to perform physical or occupational tasks that require sustained activity, walking, or speaking over extended periods.  The examiner opined that the Veteran's disability as secondary to a left leg amputation due to a left lower extremity varicose vein disability was not related to his military service.  However, the examiner concluded in the opinion that the Veteran's lung disability is the result of "prolonged intubation and tracheostomy" rather than a direct physiological outcome of the Veteran's amputation.  The examiner further noted that "while there is a clear temporal relationship between the amputation and the development of diaphragmatic dysfunction, the phrenic nerve injury is medically attributable to complications of "prolonged mechanical ventilation," not to the amputation itself or to the underlying vascular insufficiency/varicose veins."

The Board finds the VA examiner's opinion inadequate.  The Board reached this conclusion because the examiner simply found that the Veteran's disorder was not related to his military service because there was not a secondary service connection between the Veteran's left leg amputation due to a left lower extremity varicose vein disability and his lung disorder.  However, the Board notes that the examiner concluded that the Veteran's right diaphragmatic paralysis and compressive atelectasis disability was causally related to a "prolonged intubation and tracheostomy" that was a complication of the left leg amputation, which then acted as a significant intermediate factor.

Based on review of the record, both lay and medical, the Board finds that the evidence is at least in relative equipoise as to whether the Veteran's diagnosed right diaphragmatic paralysis and compressive atelectasis, to include as secondary to service-connected left leg amputation associated with a left lower extremity varicose veins disability with prolonged intubation and ventilatory support acting as a significant intermediate factor is related to service.  The most probative opinions of record, the June 
 right diaphragmatic paralysis and compressive atelectasis disability was causally related to a "prolonged intubation and tracheostomy" that was a complication of the left leg amputation, which then acted as a significant intermediate factor.

Based on review of the record, both lay and medical, the Board finds that the evidence is at least in relative equipoise as to whether the Veteran's diagnosed right diaphragmatic paralysis and compressive atelectasis, to include as secondary to service-connected left leg amputation associated with a left lower extremity varicose veins disability with prolonged intubation and ventilatory support acting as a significant intermediate factor is related to service.  The most probative opinions of record, the June 2025 VA examination conclusion weighing in favor of the claim "with prolonged intubation and ventilatory support acting as a significant intermediate factor" and the June 2025 VA examination opinion weighing against the claim are equally probative.  In other words, the Board finds that the positive and negative evidence of record is in approximate balance.  Accordingly, the Board resolves any reasonable doubt in the appellant's favor and finds that entitlement to service connection for a right diaphragmatic paralysis and compressive atelectasis, to include as secondary to service-connected left leg amputation associated with a left lower extremity varicose veins disability with prolonged intubation and ventilatory support acting as a significant intermediate factor, is therefore warranted.  38 U.S.C. § 5107; 38 C.F.R. § 3.102.  

 

 

Michael J. Skaltsounis

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	W. Taylor

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.