RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX.	CASE:  PD-2016-00560
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20041101

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Indirect Fire Infantryman, medically separated for “post-traumatic headaches” and “right ear hearing loss,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  “Review all conditions.”  The complete submission is at Exhibit A.

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting or non-compensable.  Any conditions outside the panel’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition(s) at the time of separation.  The panel has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The panel gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:

SERVICE PEB - 20040827	VARD - 20050805	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Post-Traumatic Headaches	8045-9304	10%	Migraines 	8100 	10% 	20050629 	
Right Ear Hearing Loss	6100	0%	Bilateral Hearing Loss 	6100 	0% 	20050624 	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Post-Traumatic Headaches.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s headache condition began on 24 February 2004 after being struck on the head with a pool stick and landing on a hard floor.  He had a brief loss of consciousness with vomiting and bleeding from the left ear.  Computerized tomography (CT) revealed a sphenoid/mastoid fracture non-displaced and an early small right parietal subarachnoid hemorrhage without a midline shift.  The CI was seen in the Emergency Room (ER) on 8 June 2004 for headaches, dizziness, and having passed out the night before.  Treatment consisted of intravenous fluids, Toradol (ketorolac, a nonsteroidal anti-inflammatory drug (NSAID)) and Reglan (metoclopramide, to treat nausea from a headache), which resolved his symptoms.  The CI was recommended for quarters for 72 hours pending evaluation by a neurologist.  A note dated 11 June 2004 indicated the CI had periods of lapse of consciousness suggestive of partial seizures, while a note dated 17 June 2004 indicated the CI had an abnormal EEG (electroencephalogram).  The neurologist noted he could have full blown seizures if he were sleep deprived.  A note dated 23 June 2004 indicated the CI was placed on phenytoin, an anticonvulsant, 2 weeks earlier, which the CI discontinued.  Onset of attacks began in May 2004, which when he stood up he felt dizzy, lightheaded and had blurred vision.  He reported having paresthesias multiple times a day.  He denied altered consciousness, unexplained odors or tastes, micropsia (objects are perceived to smaller than they are), macropsia (objects appear larger than normal), depersonalization, confusion, bowel or bladder incontinence, tongue lacerations, or other associated symptoms.  Headaches began in February 2004.  A typical headache started in the right parietal region and radiated to the entire head and was a constant pain associated with nausea.  He denied photophobia or photophobia.  The headaches lasted for 1 hour and occurred five to six times a day and occurred daily.  They were aggravated by movement and exercise.  The examiner’s impression was post-traumatic headaches and treatment consisted of Midrin (a combination of acetaminophen, dichloralphenazone, and isometheptene to relieve pain, tension and migraine headaches) for abortive treatment and Depakote ER (valproic acid (divalproex sodium), an anticonvulsant to treat epilepsy, bipolar and migraines) for headache prophylactic treatment.  

The 23 June 2004 MEB NARSUM examination, 4 months prior to separation, noted complaints of daily headaches since February 2004.  As a result the CI was unable to run secondary to triggering the headaches.  Physical examination showed cranial nerves II-XII intact, no papilledema (retinal swelling), and pupils equal and reactive to light.  Past treatment consisted of Naprosyn (naproxen, a nonsteroidal anti-inflammatory drug (NSAID)), Motrin (ibuprofen, an NSAID), and Tylenol (acetaminophen, a pain reliever).  During the 1 July 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation the examiner noted post-traumatic headaches after a skull fracture and subarachnoid hemorrhage.  Physical examination showed a hard nodule on the occipital area of the head.   

The 30 July 2004 MEB NARSUM Addendum, 3 months prior to separation, noted complaints of continued headaches five to six times per day on a daily basis despite initiation of Depakote ER for headache prophylaxis and Midrin for abortive treatment of the headaches.  The headaches remained unchanged in character except for a new development of photophobia in association with the headache.  Midrin was noted to alleviate some of the headache severity.  

At the 29 June 2005 VA Compensation and Pension (C&P) evaluation, 8 months after separation, the CI reported daily headaches in the right temporal area occurring every 4 hours lasting 1-2 hours triggered by bright light and noise.  After the head injury he noticed significant problems with concentration.  He was physically inactive during episodes of headache. Physical examination showed the CI to be alert and oriented in no acute distress.  Neurologic examination was unremarkable and his hearing (cranial nerve VIII) was assessed by audiology.  At the time of the examination, the CI was not taking any medication.  Naproxen and Tylenol were ineffective, and he had been prescribed gabapentin (for nerve pain), but had not yet started it.  An MRI dated 30 April 2005 demonstrated no evidence of restricted diffusion with normal structures, no evidence of intra or extra-axial lesions, and the posterior fossa and midline structures were in normal position.  The CI experienced lack of concentration, lack of motivation, and a feeling of sadness. The examiner’s impression was head injury/skull fracture with post-concussion syndrome and secondary chronic migraine headaches with a mild functional loss.  Although he had some concentration problems as part of his post-concussive syndrome, there was no evidence for an actual memory disorder. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the post-traumatic headache condition 10%, coded 8045-9304 (brain disease due to trauma-dementia due to head trauma).  The VA rated the headache condition 10%, coded 8100 (migraine), based on the C&P examination 8 months after separation, citing prostrating headaches averaging one in two months over the last several months.

Members noted that the VASRD in 2004 indicated that code 8045 stated:  “Brain disease due to trauma:  Purely subjective complaints such as headache, dizziness, insomnia, etc., recognized as symptomatic of brain trauma, will be rated 10 percent and no more under diagnostic code 9304. This 10 percent rating will not be combined with any other rating for a disability due to brain trauma.  Ratings in excess of 10 percent for brain disease due to trauma under diagnostic code 9304 are not assignable in the absence of a diagnosis of multi-infarct dementia associated with brain trauma.”  However, there was no diagnosis of multi-infarct dementia.  Members noted that the VA used code 8100 for a 10% rating, which offers no benefit to the CI; and, there was no evidence of “characteristic prostrating attacks occurring on an average of once a month over last several months” to warrant a higher rating of 30% with the use of code 8100.  Therefore, there was no route to a higher rating using codes 8045, 9304, or 8100.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the post-traumatic headaches condition.

Right Ear Hearing Loss.  According to the STR and the MEB NARSUM, the CI’s right ear hearing loss began in February 2004 after the head trauma described above.  At an audiological evaluation dated 17 March 2004 the CI complained of hearing loss without otorrhea (fluid drainage from the ear).  There was tinnitus (ringing) in the right ear with balance problems and dizziness.  An audiogram revealed mild sloping to profound CHL (complete hearing loss) on the right with an average loss of 46 dB (30 dB at 1000 Hz, 45 dB at 2000 Hz, 50 dB at 3000 Hz, and 60 dB at 4000 Hz), a 100 dB loss at 6000 Hz, and no response at 8000 Hz.  There was  normal hearing through 3000 Hz to moderately severe sensorineural hearing loss on the left with an average loss of 21 dB (15 dB at 1000 Hz, 10 dB at 2000 Hz, 15 dB at 3000 Hz, and 45 dB at 4000 Hz).  The tympanic membranes were normal bilaterally and the reflexes were within normal limits on the left, but the audiologist CNE (could not examine) the right due to tympanic membrane movement.  There was excellent speech discrimination in both ears in a quiet setting.  

During the 1 July 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation the CI reported a conductive hearing loss and dislocated ear bone.  Physical examination showed grossly decreased hearing to soft sounds.  The examiner was able to visualize half of the tympanic membrane as normal and the other half dark.  Average hearing loss on the right was 46 dB and 100 dB loss at 6000 Hz.  Average hearing loss on the left was 21 dB with a 60 dB loss at 6000 Hz.  A CT of the temporal bones on 5 March 2004 showed a longitudinal fracture through the temporal bone, which extended through the mastoid air cells, external auditory canal through the tympanic cavity, temporomandibular joint, and the cavernous portion of the carotid artery on the right.

The 28 July 2004 MEB NARSUM Addendum examination, 3 months prior to separation, noted complaints of hearing loss post injury with a skull base fracture with sudden onset of conductive hearing loss with ringing in the ears and occasional balance problems and dizziness, which resolved. The CI had a history of noise exposure consistent with military service.  Physical examination showed intact bilateral tympanic membranes and no evidence of chronic middle ear disease.  There was a conductive hearing loss of approximately 35 dB (decibels), which had a mild sloping to profound mixed hearing loss throughout the frequency range of hearing in the right ear consistent with an ossicular chain disruption.  The left ear had normal hearing through 3000 Hz sloping to moderate to severe neurosensory hearing loss.  

At the 29 June 2005 C&P evaluation the CI reported right ear hearing loss and constant tinnitus since the head trauma  and fracture of the temporal bone.  Physical examination showed clear external auditory canals and visible tympanic membranes.  Audiological findings revealed a mild-profound, primarily conductive hearing loss at the right ear with an average loss of 53 dB and normal hearing loss of the left ear through 3000 Hz and a moderately severe-mild sensorineural hearing loss of notch-like configuration at 4000 Hz and above with an average loss of 18 dB.  Word recognition was excellent bilaterally and tympanometry demonstrated a hypercompliant right tympanic membrane with normal middle ear pressure and the left had normal tympanic membrane mobility and normal middle ear pressure.  Ipsilaterally stimulated acoustic reflexes in the probe-right condition were likely artifact.    

The hearing evaluations in evidence, which the panel weighed in arriving at its rating recommendation with documentation of additional ratable criteria, are summarized in the chart below.

HEARING	EXAM	MEB  ~8 Mo. Pre Sep
20040317	VA ~8 Mo. Post Sep
20050829	
LEFT EAR	Average Hearing Loss	21 dB	18 dB	
	Speech Discrimination	Excellent	Excellent	
	Table VI / VIa	I	I	
RIGHT EAR	Average Hearing  Loss	46 dB	53 dB	
	Speech Discrimination 	Excellent	Excellent	
	Table VI / VIa	I/II	I/III	
§4.85 RATING	Table VII	0%	0%	

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right ear hearing loss 0%, coded 6100 (hearing impairment).  The VA rated the bilateral hearing loss condition 0%, coded 6100, based on the C&P examination 8 months after separation, citing non-compensable hearing impairment.  Members noted that although the CI had profound conductive hearing loss of the right ear at 6000 Hz and 8000 Hz; nonetheless,  rating for hearing loss is based on the “pure tone threshold average,” which is the average loss in decibels from 1000 Hz to 4000 Hz IAW VASRD §4.85 and §4.86.  Therefore, there is no route to a higher rating for the hearing loss.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right ear hearing loss.  

BOARD FINDINGS:  In the matter of the post-traumatic headaches and IAW VASRD §4.124a the panel unanimously recommends no change in the PEB adjudication.   In the matter of the right ear hearing loss and IAW VASRD §4.85 and §4.86, the panel unanimously recommends no change in the PEB adjudication.  There were no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160912, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	
AR20170015816, XXXXXXXXXXXXXXXXXX. 

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					       
						      					
Enclosure