FACIAL NERVE (VII CRANIAL NERVE) PARALYSIS

Summary

The Veteran, who served in the United States Air Force from January 1994 to May 2000, appeals the denial of service connection for three conditions: occasional slurred speech (also claimed as a lip condition), cellulitis secondary to a service-connected right ankle disability, and intrauterine shedding due to exposure to contaminated water at Ellsworth Air Force Base. The Board found that the Veteran's in-service injury for slurred speech (lip trauma) was conceded, but the record lacked competent evidence of a current diagnosis or persistent symptoms of slurred speech. The Board noted that while the Veteran had an in-service injury to her lip and later reported mouth sores, there was no indication of slurred speech in post-service treatment records or lay statements. Consequently, service connection for slurred speech was denied. The Board remanded the claims for cellulitis and intrauterine shedding. For cellulitis, the Veteran had an in-service injury and subsequent cellulitis, with persistent ankle pain and a post-service rash. For intrauterine shedding, the Veteran had multiple gynecological issues during service, including heavy bleeding and pelvic pain, and was diagnosed with chronic cervicitis post-service. However, the Board found no evidence linking these conditions to contaminated water at Ellsworth Air Force Base. As the criteria for a VA examination were met for cellulitis and intrauterine shedding due to insufficient competent medical evidence, these claims were remanded for the AOJ to obtain medical opinions addressing nexus to service, TERA, aggravation by service-connected conditions, and medication effects.

Rationale

No competent evidence of current slurred speech; No persistent symptoms of slurred speech post-service; In-service lip injury conceded, but no link to slurred speech established

Full Decision Text

Citation Nr: A26037314
Decision Date: 04/21/26	Archive Date: 04/21/26

DOCKET NO. 251005-596633
DATE: April 21, 2026

ORDER

Entitlement to service connection for a disability manifested by occasional slurred speech (also claimed as lip condition) is denied.

REMANDED

Entitlement to service connection for cellulitis, to include as secondary to the Veteran's service-connected right ankle disability, is remanded.

Entitlement to service connection for intrauterine shedding, to include as secondary to the Veteran's service-connected disabilities, is remanded.

FINDING OF FACT

The record on review does not indicate that the Veteran has a disability manifested by occasional slurred speech. 

CONCLUSION OF LAW

The criteria for service connection for a disability manifested by occasional slurred speech are not met. 38 U.S.C. § 1110, 38 C.F.R. § 3.303, 3.304.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served in the United States Air Force from January 1994 to May 2000.

The decision on appeal to the Board of Veterans' Appeals (Board) from the regional office (referred to as the Agency of Original Jurisdiction (AOJ)), was issued in November 2024 as a higher-level review decision. Therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies.  

In September 2023, the Veteran filed VA Form 21-526EZ (Claim) requesting service connection for occasional slurred speech, as a result of domestic violence perpetrated against her by her ex-husband, a senior Non-Commissioned Officer; cellulitis, as secondary to the Veteran's service-connected right ankle disability; and intrauterine shedding, as due to exposure to contaminated water at Ellsworth Air Force Base. In January 2024, the AOJ denied service connection for all three issues. 

In August 2024, the Veteran filed VA Form 20-0996 (Request for Higher-Level Review) requesting review of the slurred speech, cellulitis, and intrauterine shedding issues addressed in the January 2024 decision.

In November 2024, the AOJ denied service connection for all three issues. In October 2025, the Veteran timely filed VA Form 10182 (Notice of Disagreement), requesting review of the November 2024 higher-level review decision denying service connection for occasional slurred speech, cellulitis, and intrauterine shedding, and requesting the Evidence Review docket. The appeal was docketed in November 2025. 

Therefore, the Board may only consider the evidence of record at the time of the January 2024 decision, which was subject to higher-level review in the November 2024 decision (identified as the decision on appeal), and any evidence submitted by the Veteran, or his Representative, with or within 90 days from receipt of, the Notice of Disagreement. 38 C.F.R. § 20.303. If evidence was submitted either (1) during the period after the AOJ issued the January 2024 decision and prior to the date the Board received the Notice of Disagreement, or (2) more than 90 days following the date the Board received the Notice of Disagreement, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 20.801.

However, because the Board is remanding the claims of entitlement to service connection for cellulitis and intrauterine shedding, any evidence the Board could not consider will be considered by the AOJ in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii).

Service Connection 

The Veteran contends that her cellulitis, slurred speech, and intrauterine shedding are due to or a result of her military service. Specifically, the Veteran reports that she has a current disability of cellulitis secondary to her right ankle disability; she has slurred speech as a result of domestic violence perpetrated against her by her ex-husband, a senior Non-Commissioned Officer; and that her current intrauterine shedding is due to exposure to contaminated water at Ellsworth Air Force Base. See September 2023 Claim. 

Relevant Legal Criteria

Service connection is granted for a disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.
 slurred speech as a result of domestic violence perpetrated against her by her ex-husband, a senior Non-Commissioned Officer; and that her current intrauterine shedding is due to exposure to contaminated water at Ellsworth Air Force Base. See September 2023 Claim. 

Relevant Legal Criteria

Service connection is granted for a disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d).

To establish service connection, a Veteran must show: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d. 1163, 1166-67 (Fed. Cir. 2004). However, in the absence of evidence of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992).

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 by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); see also Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (invalidating the requirement of "proximate cause" and instead holding that "but for" causation or aggravation is sufficient to show entitlement to secondary service connection).

Lay testimony is competent to describe the presence of readily observable features or symptoms of injury or illness that are not medical in nature. 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303, 307-310 (2007). Additionally, the Board is bound by favorable findings by the AOJ in the absence of evidence of clear and unmistakable error. 38 C.F.R. § 3.104(c).

In McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006), the United States Court of Appeals for Veterans Claims (Court) indicated that there is a four-part test to determine whether an examination is necessary under 38 C.F.R. § 3.159(c)(4). Under this test, VA will provide a medical examination or obtain a medical opinion where 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; (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; and (4) there is insufficient competent medical evidence to make a decision on the claim. Id. 

Further, the threshold for determining whether the evidence "indicates" that there "may" be a nexus between a current disability and an in-service event is a low one.  Id. at 83. Moreover, pain resulting in functional impairment qualifies as a disability. See Saunders?v. Wilkie, 886 F.3d 1356, 1364 (Fed. Cir. 2018). 

Finally, under the AMA, unless the claim on appeal can be granted in full, the Board shall remand the appeal to the AOJ for correction of an error by the AOJ which occurred prior to the rating decision on appeal, including those relating to VA examinations. The Board may also remand for correction of any other error by the AOJ to satisfy a regulatory or statutory duty, if correction of the error would have a reasonable possibility of aiding in substantiating the Veteran's claim. See 38 C.F.R. § 20.802.

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Facts and Analysis

To begin, the AOJ conceded that the Veteran had an in-service incurrence of disease and/or injury for all three appealed issues. See November 2024 Rating Decision (finding that the Veteran had cellulitis in May 1997 after a right ankle sprain; the Veteran had a minor lip laceration in November 1999 after wrestling with her husband; and the Veteran was seen in October 1998 for intermenstrual bleeding with pelvic pain, passing tissue, and soft tissue in her
J to satisfy a regulatory or statutory duty, if correction of the error would have a reasonable possibility of aiding in substantiating the Veteran's claim. See 38 C.F.R. § 20.802.

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Facts and Analysis

To begin, the AOJ conceded that the Veteran had an in-service incurrence of disease and/or injury for all three appealed issues. See November 2024 Rating Decision (finding that the Veteran had cellulitis in May 1997 after a right ankle sprain; the Veteran had a minor lip laceration in November 1999 after wrestling with her husband; and the Veteran was seen in October 1998 for intermenstrual bleeding with pelvic pain, passing tissue, and soft tissue in her uterus). 38 C.F.R. § 3.104(c). 

As such, the question then becomes whether the Veteran has a current diagnosis for each claimed issue and whether there is a link between the diagnoses and the in-service diseases and/or injuries, or a service-connected disability. Shedden, 381 F.3d. at 1166-67. 

The relevant evidence on review includes service treatment records, military personnel records, treatment records, a VA examination from 2001, and photographs (received October 2025, following the November 2024 higher-level review decision on appeal).  

The Board notes that the Veteran did not attend the VA examinations scheduled for the claimed issues; rather, she stated that she did not want to be scheduled for VA examinations as she had "been subject to maltreatment by the VA Healthcare system." See August 2024 Request for Higher-Level Review. Additionally, no current medical opinions were obtained. 

The Veteran's entrance examination noted a normal mouth, lower extremity, and pelvic examination. See November 1992 Report of Medical Examination. Additionally, the Veteran did not report any lip, cellulitis, female disorders, or changes in her menstrual pattern. See November 1992 Report of Medical History. 

On exiting the military, the Veteran reported a tumor, growth, cyst, or cancer; blood in the urine; recent weight gain or loss; a change in her menstrual pattern; skin disease; swollen gums and sores in her mouth; a head injury; and depression; among other issues. See April 2000 Report of Medical History.  

Occasional Slurred Speech

During service, the Veteran was seen for lip trauma. See November 1999 Service Treatment Records (noting that the Veteran's husband hit the Veteran's lip with his elbow; the laceration was 1.5 long and 1mm deep; and that the laceration had flattened out and was healing well). 

Yet following service, the records do not indicate that the Veteran had slurred speech. Rather, the Veteran's speech was recorded as calm but energetic, less pressured and slower, rapid, serious, somewhat pressured, at normal speed with some laughter, and normal with regard to content and clarity but production was accelerated. See June-November 2001 VA Treatment Records; May 2001 Treatment Records (stating that the Veteran's lips, teeth, and gums were normal); May 2004 Education Records (reporting normal speech); August 2009 VA Treatment Records (reporting that the Veteran complained that she had sores in her mouth). 

Apart from the photographs submitted by the Veteran in October 2025, the record is silent for recent complaints or diagnoses for the Veteran's claimed lip condition causing occasional slurred speech. See October 2025 Photographs. Additionally, there are no lay statements reporting any instances of slurred speech by the Veteran or her peers. 

The Board is sympathetic to the Veteran; however, the Board is bound by the applicable laws and regulations. 38 U.S.C. § 7104(c) ("The Board shall be bound in its decisions by the regulations of the Department, instructions of the Secretary, and the precedent opinions of the chief legal officer of the Department"); 38 C.F.R. § 20.105 ("In the consideration of appeals and in its decisions, the Board is bound by applicable statutes, regulations of the Department of Veterans Affairs, and precedent opinions of the General Counsel of the Department of Veterans Affairs").

Here, although the Veteran's in-service injury is conceded, there is no competent evidence that the Veteran exhibits slurred speech, or has a disability that manifests as such. See November 2024 Rating Decision. Rather, the record only supports that the Veteran had sores in her mouth after service. See August 2009 VA Treatment Records. As such, element one (competent evidence of a current disability or persistent or recurrent symptoms of a disability) is not met, and the appeal for occasional slurred speech (lip condition) must be denied. McLendon, 20 Vet. App. at 81; Brammer v. Derwinski, 3 Vet
, and precedent opinions of the General Counsel of the Department of Veterans Affairs").

Here, although the Veteran's in-service injury is conceded, there is no competent evidence that the Veteran exhibits slurred speech, or has a disability that manifests as such. See November 2024 Rating Decision. Rather, the record only supports that the Veteran had sores in her mouth after service. See August 2009 VA Treatment Records. As such, element one (competent evidence of a current disability or persistent or recurrent symptoms of a disability) is not met, and the appeal for occasional slurred speech (lip condition) must be denied. McLendon, 20 Vet. App. at 81; Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992).

REASONS FOR REMAND

Cellulitis 

During service, the Veteran reported injuring her right ankle and then developed cellulitis as a result of an open abrasion. See May-June 1997 Service Treatment Records. Although the cellulitis resolved, the Veteran reported right ankle pain in September 1997, November 1997, and January 1998. Following service, the Veteran was seen for a severe rash on her ankle, diagnosed as an erythematous edematous rash. See June 2004 Education Records; October 2025 Photographs (demonstrating an apparent rash on the Veteran's right ankle). 

Intrauterine Shedding 

The Board notes that the Veteran's personnel records demonstrate that the Veteran was stationed at Ellsworth Air Force Base from at least 1996 to 2000. See generally Military Personnel Records. 

During service, the Veteran was seen for pain in her lower abdomen in April 1996; she was seen for a lipoma on the left side of her abdomen in September 1996; an ovarian cyst in January 1997; she reported heavy vaginal bleeding in August 1998; vaginal bleeding with mucus in September 1998; she reported chronic pelvis pain in September 1998; passing tissue from her vagina in October 1998; and pelvic pain in November 1998. See April 1996, September 1996, January 1997, August - November 1998 Service Treatment Records; August 2001 VA Examination (noting that the Veteran had a possible miscarriage while on active duty). 

Additionally, the Veteran reported a history of chlamydia in April 1999; she had a laparoscopy in October 1999, demonstrating redundant urachnal tissue on the anterior abdominal wall; and a 1.5 cm multi-lobulated mass located anteriorly and superiorly to the bladder was identified in October 1999. See April 1999, October 1999 Service Treatment Records. 

The Veteran's records also note a history of dyspareunia in November 1999; and an enlarged lymph node in the vaginal/left inguinal area was located in November 1999. See November - December 1999, February 2000 Service Treatment Records (stating that in February 2000, the Veteran's clinician noted that the Veteran had been seen for left inguinal and left hip pain for approximately four years following the birth of her child; and stating that the clinician "had a frank discussion of [the Veteran's] somatization [disorder] . . . . [discussing] the implications [on how] the brain responds to mental [stress, depression, and coping] mechanisms"). 

The Veteran was medically discharged from service in May 2000. See February 2000 Medical Evaluation Board Summary (noting that the Veteran's final diagnoses included somatization disorder; posttraumatic stress disorder; depressive disorder; borderline and paranoid personality traits; multiple occupational, familial, and social stressors; chronic pelvic pain secondary to the somatization disorder; and a history of irritable bowel syndrome); DD Form 214 (stating that the Veteran was discharged in May 2000 and awarded disability severance pay). 

Following service, the Veteran was seen for abnormal pap smear results demonstrating ASCUS and AGUS. The Veteran was diagnosed with chronic cervicitis and reactive squamous metaplasia. See July-August 2001 Private Treatment Records. Additionally, the Veteran reported having heavy periods. See November 2004 Education Records; August 2009 VA Treatment Records.

Currently, there is no evidence indicating that contaminated water at Ellsworth Air Force Base has been linked to or contributed to her intrauterine shedding symptoms, including abdominal pain, lipoma, ovarian cyst, heavy vaginal bleeding, chronic pelvis pain, passing tissue through her vagina, a possible miscarriage, redundant urachnal tissue, the 1.5 cm multi-lobulated internal mass, dyspareunia, enlarged lymph node, and abnormal
 ASCUS and AGUS. The Veteran was diagnosed with chronic cervicitis and reactive squamous metaplasia. See July-August 2001 Private Treatment Records. Additionally, the Veteran reported having heavy periods. See November 2004 Education Records; August 2009 VA Treatment Records.

Currently, there is no evidence indicating that contaminated water at Ellsworth Air Force Base has been linked to or contributed to her intrauterine shedding symptoms, including abdominal pain, lipoma, ovarian cyst, heavy vaginal bleeding, chronic pelvis pain, passing tissue through her vagina, a possible miscarriage, redundant urachnal tissue, the 1.5 cm multi-lobulated internal mass, dyspareunia, enlarged lymph node, and abnormal pap smears. See November 2024 Deferred Rating Decision (stating that no toxic exposure risk activities (TERA) have been conceded; VA does not concede exposure to contaminated water at Ellsworth Air Force Base; absent current diagnosed disabilities for the claimed conditions, TERA is moot). 

As noted above, VA must provide an examination and/or obtain an 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; (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; and (4) there is insufficient competent medical evidence to make a decision on the claim. McLendon, 20 Vet. App. at 81.

Here, the Veteran was diagnosed with a right ankle erythematous edematous rash following service. See June 2004 Education Records. Additionally, the Veteran's treatment records demonstrate that she complained of heavy periods in 2004 and 2009; and she was diagnosed with chronic cervicitis and reactive squamous metaplasia. See July-August 2001 Private Treatment Records; November 2004 Education Records; August 2009 VA Treatment Records. 

When considering the Veteran's September 2023 Claim, the photograph demonstrating an apparent rash on the Veteran's ankle (submitted after the decision on review), and the treatment records discussed above, the record as a whole indicates that the Veteran has continued to have persistent or recurrent symptoms of a right ankle rash or cellulitis and intrauterine shedding. See September 2023 Claim; October 2025 Photographs; November 2024 Rating Decision (finding that the Veteran had an in-service incurrence of disease or injury for all three claimed issues); McLendon, 20 Vet. App. at 81; 38 C.F.R. § 3.104(c).

As such, McLendon elements one, two, and three are met for the Veteran's claimed cellulitis and intrauterine shedding. As there are no recent medical opinions associated with the Veteran's claimed right ankle cellulitis and intrauterine shedding, there is insufficient competent evidence to decide the claim and the low bar for remand is met. McLendon, 20 Vet. App. at 81; Saunders, 886 F.3d at 1364. 

As such, the matters are remanded so that the AOJ may obtain medical opinions. 38 C.F.R. § 20.802.

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The matters are REMANDED for the following action:

Obtain medical opinions from an appropriate clinician regarding the nature and etiology of the Veteran's claimed right ankle cellulitis and intrauterine shedding, to include as due to any conceded toxic exposure risk activity (TERA). 

Based on a review of the record, the examiner is asked to respond to the following:

(a.) Is it at least as likely as not (likelihood?is at least approximately balanced or nearly equal, if not higher) that the Veteran's claimed right ankle cellulitis and/or intrauterine shedding, to include any pain resulting in functional impairment, had onset in service, or is otherwise related to service, to include participation in a TERA? In addressing this question, the examiner should 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.

(b.) Determine whether it is at least as likely as not (i.e., likelihood is at least approximately balanced or nearly equal) that the Veteran's service-connected disabilities caused her claimed right ankle cellulitis and/or intrauterine shedding. Why or why not?

(c.) Determine whether it is at least as likely as not (i.e., likelihood is at least approximately balanced or nearly equal) that the Veteran's service-connected disabilities aggravated her claimed right ankle cellulitis and/or intrauterine shedding. Why or why not?

(d.) Determine whether it is at least as likely as not (i.e., likelihood is at least approximately balanced or
 the Veteran, and (B) the synergistic, combined effect of all toxic exposure risk activities of the Veteran.

(b.) Determine whether it is at least as likely as not (i.e., likelihood is at least approximately balanced or nearly equal) that the Veteran's service-connected disabilities caused her claimed right ankle cellulitis and/or intrauterine shedding. Why or why not?

(c.) Determine whether it is at least as likely as not (i.e., likelihood is at least approximately balanced or nearly equal) that the Veteran's service-connected disabilities aggravated her claimed right ankle cellulitis and/or intrauterine shedding. Why or why not?

(d.) Determine whether it is at least as likely as not (i.e., likelihood is at least approximately balanced or nearly equal) that the medications the Veteran takes for her service-connected disabilities caused her claimed right ankle cellulitis and/or intrauterine shedding. Why or why not? 

(e.) Determine whether it is at least as likely as not (i.e., likelihood is at least approximately balanced or nearly equal) that the medications the Veteran takes for her service-connected disabilities aggravated her claimed right ankle cellulitis and/or intrauterine shedding. Why or why not? 

For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. 

For the purpose of responding to the questions posed above, the Board notes that the Veteran is currently service-connected for the following disabilities: posttraumatic stress disorder and somatoform disorder; right sprained ankle with status post synovectomy and resection of os trigonum; irritable bowel syndrome and gastroesophageal reflux disorder; left maxillary sinus cyst with mild seasonal allergic rhinitis; residual scar from left inguinal lymph node biopsy; asymptomatic scar, status post lipoma excision on the left flank; and episodic myofascial pain due to stress related clinching.

Additionally, the examiner is asked to include consideration of the Veteran's diagnoses of right ankle erythematous edematous rash (cellulitis) and chronic cervicitis and reactive squamous metaplasia (intrauterine shedding). See June 2004 Education Records; July-August 2001 Private Treatment Records.

The examiner is also asked to consider the Veteran's intrauterine shedding symptoms, including: abdominal pain, lipoma, ovarian cyst, heavy vaginal bleeding, chronic pelvis pain, passing tissue through her vagina, a possible miscarriage, history of chlamydia, redundant urachnal tissue, the 1.5 cm multi-lobulated internal mass, dyspareunia, enlarged lymph node, and abnormal pap smears. See June 2004 Education Records; April 1996, September 1996, January 1997, August - November 1998 Service Treatment Records; August 2001 VA Examination; April 1999, October 1999 Service Treatment Records; November - December 1999, February 2000 Service Treatment Records; July-August 2001 Private Treatment Records; November 2004 Education Records; August 2009 VA Treatment Records.

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

The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion (e.g., diagnosis, etiology) as it is to find against the conclusion.

The examiner is advised that the Veteran is competent to report her symptoms and history, and such reports must be acknowledged and considered in formulating any opinion.

The examiner should also be aware that in rendering an opinion, it must "contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two." See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008).

Furthermore, if medical literature is relied upon in rendering this determination, the VA examiner should identify and specifically cite each reference material utilized.

Citation to accepted medical literature and principles would be of great assistance to the Board.  

 

 

M. C. WILSON

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	L. Davidson

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.