SINUSITIS

Summary

The veteran, who served from September 1975 to July 1976, appeals the denial of service connection for chronic sinusitis and the remand of his lumbar spine disability claim. The Board reviewed the evidence of record at the time of the September 2020 AOJ decision, excluding evidence submitted after the Board hearing. For the sinusitis claim, the Board found the evidence persuasively against a current chronic sinusitis diagnosis related to service. While service treatment records showed acute sinusitis and upper respiratory infections during service, the separation examination noted normal sinuses, and post-service records were silent on the issue. The VA examiner in November 2019 found no current sinusitis diagnosis and noted the condition was acute only during service. A private nexus opinion from January 2020 was deemed inadequate due to lack of rationale and failure to address the VA opinion. The veteran's spouse, an RN, provided a statement in January 2025 regarding daily sinus symptoms, but the Board found it lacked probative value as her RN status did not qualify her for medical diagnosis, and her statement did not establish continuity of symptoms from service. The Board denied service connection for chronic sinusitis. The lumbar spine claim was remanded due to a pre-decisional duty to assist error; the VA opinion was inadequate for failing to address in-service complaints of back pain and their potential link to a vertebral disc injury, and for lacking rationale for its conclusion.

Rationale

Service treatment records showed acute sinusitis during service.; Separation examination found normal sinuses.; Post-service medical records are silent for sinus issues.; VA examiner found no current diagnosis of sinusitis.; Private nexus opinion was inadequate due to lack of rationale.

Full Decision Text

Citation Nr: A26040346
Decision Date: 04/29/26	Archive Date: 04/29/26

DOCKET NO. 201013-115401
DATE: April 29, 2026

ORDER

Entitlement to service connection for chronic sinusitis is denied.

REMANDED

Entitlement to service connection for a lumbar spine disability is remanded.

FINDING OF FACT

The competent and credible evidence of record does not show a currently diagnosed chronic sinusitis condition.

CONCLUSION OF LAW

The criteria for entitlement to service connection for sinusitis have not been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a).

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from September 1975 to July 1976.

In the October 2020 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held on December 2, 2024.

Therefore, the Board may only consider the evidence of record at the time of the September 2020 agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran or his representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801. 

Evidence was added to the claims file during a period of time when new evidence was not allowed. As the Board is deciding the claim of service connection for chronic sinusitis, it may not consider this evidence in its decision.  38 C.F.R. § 20.300.  The Veteran may file a Supplemental Claim and submit or identify this evidence.  38 C.F.R. § 3.2501.  If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. 

However, because the Board is remanding the service connection claim for a lumbar spine disability, any evidence the Board could not consider will be considered by the AOJ in its adjudication. 38 C.F.R. § 3.103(c)(2)(ii).

Entitlement to service connection for sinusitis.

Service connection on a direct basis requires (1) competent and credible evidence confirming the Veteran has the claimed disability or at least has since filing the claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or injury; and (3) competent and credible evidence of a nexus or link between the in-service injury or disease and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes that the disease was incurred in service. See 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d).    

Presumptive service connection can satisfy the requirements of an in-service event and a nexus to military service. Chronic diseases listed under 38 C.F.R. § 3.309(a)-(f) that manifest either during active service or subject to the requirements of 38 C.F.R. § 3.307 after discharge or release from military service are sufficient to establish in-service incurrence or aggravation. If a chronic disease enumerated in 38 C.F.R. § 3.309 does not manifest in-service or within the applicable time limits, the second and third elements of service connection may be granted based on continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The United States Court of Appeals for the Federal Circuit (Federal Circuit) clarified that the law providing for awards of service connection on the basis of continuity of symptomatology is limited to those "chronic" diseases listed under 38 C.F.R. § 3.309(a). See Id.

The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the
 the applicable time limits, the second and third elements of service connection may be granted based on continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The United States Court of Appeals for the Federal Circuit (Federal Circuit) clarified that the law providing for awards of service connection on the basis of continuity of symptomatology is limited to those "chronic" diseases listed under 38 C.F.R. § 3.309(a). See Id.

The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the evidence of record is persuasively against finding that the Veteran has a current chronic sinusitis disability that was incurred in or is causally related to his service.

The Veteran's service treatment records (STRs) show that during service, he sought treatment for sinus symptoms on multiple occasions. In January 1976, he complained of sore threat, rhinorrhea, and sinus congestion. The diagnosis was sinusitis. In February 1976, he reported an upper left toothache; sinus X-ays were negative, and the Veteran was returned to duty. In March 1976, the Veteran reported sinus congestion; the Veteran's provider diagnosed an upper respiratory infection. However, the July 1976 separation examination found the Veteran's sinuses to be normal. The Veteran's post service medical treatment records are silent for any complaints or treatment of sinus issues; no diagnosis of sinusitis (acute or chronic) is documented. 

At the VA examination in November 2019, the examiner did not provide a diagnosis of sinusitis. The examiner noted that on physical examination, the Veteran's sinuses were normal, and that during service, the condition was acute only, and the Veteran denied sinus problems at his July 1976 separation examination. There was also no chronicity of care.

In January 2020, the Veteran submitted a private nexus statement from his private provider. The private opinion stated that the Veteran had recurrent sinusitis while in service. However, the opinion is inadequate because there is no rationale on how the opinion was made or a discussion of the November 2019 VA opinion that found no diagnosis of sinusitis. Thus, the Board finds the January 2020 private opinion to be of little probative value.

At his December 2024 Board hearing, the Veteran testified that his sinus issues began during service and that his sinus symptoms have continued since service. The Veteran reported using over-the counter (OTC) medication to treat his sinus issues. The Veteran further testified that his private medical treatment records were unavailable. 

In January 2025, the Veteran submitted a statement from his spouse, a registered nurse (RN) who stated that she had known the Veteran for more than 20 years and had witnessed the Veteran experience daily symptoms of chronic sinusitis with excessive stuffiness and nasal drainage. The statement further noted that the Veteran uses OTC medications and oral medication with minimal relief. Although the Veteran's spouse is an RN, the record does not show that as an RN she is competent to make a medical diagnosis or identify a specific disease or illness. Her statement that she had known the Veteran for 20 years also does not establish continuity of symptoms between the Veteran's separation from service, which again did not note any sinus problems, and the time that she met him. Therefore, the Board does not find the January 2025 statement probative that the Veteran has a diagnosis of chronic sinusitis or that he had ongoing symptoms since service.

Although lay persons are competent to provide opinions on some medical issues, the diagnosis and etiology of a sinus disability is outside the realm of common knowledge of a lay person because it involves complex medical issues that go beyond a simple and immediately observable cause-and-effect relationship. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007).

For these reasons, service connection for chronic sinusitis is not warranted, and the appeal is denied. In reaching the conclusions stated above, the Board has considered the applicability of the benefit of the doubt doctrine.  As the evidence persuasively favors one side or the other, the doctrine is not for application.  See Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc); 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

REASONS FOR REMAND

Entitlement to service connection for a lumbar spine disability.

The claim must be remanded because of a pre-decisional duty to assist error. The November 2019 VA
 sinusitis is not warranted, and the appeal is denied. In reaching the conclusions stated above, the Board has considered the applicability of the benefit of the doubt doctrine.  As the evidence persuasively favors one side or the other, the doctrine is not for application.  See Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc); 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

REASONS FOR REMAND

Entitlement to service connection for a lumbar spine disability.

The claim must be remanded because of a pre-decisional duty to assist error. The November 2019 VA medical opinion is inadequate. 

The opinion states that the Veteran's degenerative arthritis of the lumbar spine is caused by advanced age and damage to a vertebral disc. The examiner then opines that it is more likely than not that the Veteran's advanced age is the cause of his lumbar spine degenerative arthritis. However, the examiner does not discuss the multiple complaints of back pain during service and whether any of these incidents could have been resulted in "damage to a vertebral disc." Thus, the opinion is inadequate. 

While the Veteran submitted an opinion that his current back disability was caused by his service, no supporting rationale for that opinion was provided. Thus, the opinion is also inadequate. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). On remand, a new VA medical opinion that addresses the multiple entries of back pain during service is warranted. 38 C.F.R. § 20.802(a).

The matters are REMANDED for the following action:

Forward copies of all pertinent records to an appropriate VA examiner to obtain a medical opinion for the Veteran's service connection claims for his back disability. If the examiner determines that an opinion cannot be provided without an examination (telehealth or in-person), one should be scheduled. 

After reviewing the claims file, the examiner is asked to opine as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any currently diagnosed back condition was incurred in or is otherwise related to service.

The examiner is asked to review and discuss the Veteran's STRs that show multiple entries of complaints of back pain.

The examiner is advised that the Veteran is competent to provide evidence of symptomatology readily apparent to him, regardless of whether the symptoms are noted in the service medical records or on the date of examination. The examiner may NOT rely on the absence of a medical record or evidence of medical treatment as the sole rationale for any negative medical nexus opinion.

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?

A complete rationale must be provided for all opinions, citing to supporting factual data and medical literature, as appropriate. If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training) and note what, if any, additional evidence would permit such an opinion to be made.

 

 

J. Kirby

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	M. G. Perkins, Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.