RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01559
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20080303

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Vehicle and Vehicular Equipment Maintenance Journeyman, medically separated for “chronic sinusitis with nasopharyngitis and epistaxis” with a disability rating of 10%.   

CI CONTENTION:  In addition to breathing problems, he requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the MEB, but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20080114	VARD -20080711	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Sinusitis with Nasopharyngitis and Epistaxis	6513	10%	Chronic Sinusitis 	6512	0%	20080602	
			Allergic Rhinitis	6522	10%	20080602	
			S/P Surgery Deviated Septum	6502	0%	20080602	
Asthma	Not Unfitting	Intermittent Exercise Induced Asthma	6602	10%	20080602	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Sinusitis with Nasopharyngitis with Epistaxis.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s chronic sinusitis condition began in April 2006 after having chronic rhinitis treated with Claritin (loratadine, an antihistamine), which did not help.  On 2 June 2006 the CI was seen in follow-up for a sinus infection.  On 15 June 2006, the CI complained of a dry throat, sinus drainage in the throat, and a lot of brown mucous from the nose.  The CI had been on 10 courses of antibiotics and was tried on several antihistamines in the prior 12 months.  Flonase (fluticasone, a nasal steroid spray) caused nose bleeds.  On examination the CI had moderately swollen turbinates.  The septum leaned left with 75% narrowing, decreased airflow, and whitish mucous.  Pulse oximetry was less than 90% oxygen saturation for 9½% of the night and a CT scan revealed minor polypoid changes of the left maxillary sinus, minimal left osteomeatal complex encroachment, and mild left nasal septal deviation.  No acute sinusitis was seen, but there were minimal changes of chronic sinusitis.  Surgery was recommended.  

On 30 September 2006 the CI underwent a septoplasty, a left endoscopic nasal antral window to remove a polyp, a tonsillectomy, and bilateral partial turbinate resections.  A note on 30 September 2006 indicated the CI’s left middle meatus was open and without drainage; his septum was straight; and his tonsillar fossa area had healed.  On 6 October 2006, the CI complained of thick green nasal discharge consistent with chronic sinusitis.  Levaquin (levofloxacin, an antibiotic) was added to the treatment protocol for residual sinusitis.  Because of continuous thick yellow drainage the CI was treated with Omnicef (cefdinir, an antibiotic) for chronic nasopharyngitis and sinusitis, and Prevacid (lansoprazole) for gastroesophageal reflux disease.  

A CT scan of the sinuses on 22 February 2007 demonstrated minimal mucosal thickening along the medial posterior wall of the left maxillary sinus and a round retention cyst in the floor of the left maxillary sinus as well as postoperative changes without evidence of acute sinusitis. The CI reported he needed to drink water from a camelback while running otherwise he had mucus and bleeding from the nose.  On 13 April 2007, the CI was seen by an otolaryngologist where examination revealed a mild septal deviation, mild inflammatory change with some mucus and no obvious polyps or pus of the medial meatus bilaterally.  His nasopharynx showed persistent adenoid tissue of mild degree and there was no evidence of a possible Rathke’s pouch (turning outward at the roof of the mouth).  A note dated 4 May 2007 indicated an MRI showed prominent adenoids but no obvious Thornwaldt’s cyst (a benign cyst located in the upper posterior nasopharynx) or other issues in the nasopharyngeal region.  On 4 June 2007, the CI had his adenoids removed for chronic adenoiditis and mucus production.  On 6 July 2007 the CI had a stable examination following the adenoidectomy.  Mucinex (guaifenesin) was prescribed to reduce the viscosity of the nasal mucus.  

The 10 November 2007 MEB NARSUM examination, 5 months prior to separation, noted complaints of a history of nasal drainage, congestion, and mucus buildup.  Physical examination showed a normal oropharynx with no tonsillar tissue noted.  His tongue was normal and there were no lesions in the throat.

At the 2 June 2008 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported constant sinus problems with interference with breathing through the nose along with nasal congestion but without any purulent discharge, hoarseness, pain, or crust.  He noted he had thick mucus in the rear of the nose and throat.  During episodes, he was not incapacitated; however, he reported he experienced 365 non-incapacitating episodes per year.  Physical examination showed the nasal septum in the midline.  The mucosa of the throat was intact without pharyngeal erythema or exudate.  There was 90% nasal obstruction on the right and 70% on the left.  Diffuse mucosal swelling was noted in both nostrils with erythema.  Tonsils were noted not to be present and sinusitis was present in the maxillary and frontal area with tenderness.  No purulent discharge from the nose was noted.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic nasopharyngitis and epistaxis condition 10%, coded 6513 (chronic maxillary sinusitis).  The VA also rated the allergic rhinitis condition 10%, coded 6522 (allergic or vasomotor rhinitis), based on the C&P examination, citing greater than 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side.  

Panel members noted the CI had recurrent sinusitis as well as having had nasal obstruction.  A 30% rating requires “three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting 4-6 weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting.”  While the CI had headaches and pain, postoperatively he still had excess mucus, but no significant purulent discharge or crusting.  Furthermore, although he reported 365 non-incapacitating episodes at the VA examination, there was no supporting evidence in the STR to back up that statement.  Therefore, the 10% assigned by the PEB was reasonable.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the chronic sinusitis with nasopharyngitis with epistaxis condition.

Contended PEB Condition:  Asthma.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition.  The contended condition was not explicitly profiled, although he had a P4 profile and it was implicated in the commander’s statement.  On 31 July 2007, the CI had a restriction of no running because if he ran less than a quarter of a mile, he became short of breath secondary to a purulent nasal discharge and began feeling as if it were closing his airway off and then he could not run.  At a pulmonary consultation on 1 August 2007 the CI indicated that at times he got short of breath with exertion and some wheezing.  He had no problems with certain dusts, chemicals, sprays, changes in weather, cold temperatures, or changes in season.  He had no allergies or significant heartburn.  On examination his lungs were clear to auscultation with no abnormal breath sounds (rales, rhonchi, or stridor).  The examiner’s assessment was that the CI had dyspnea that appeared to be very mild with some mild wheezing, specifically with exertion, but without symptoms when he was not exerting himself.  He had significant nasal drainage.  Spirometry showed a moderate obstructive lung defect with flattening of the expiratory curve suggestive of an intrathoracic obstructive lung defect.  His nasal drainage and congestion may have made his underlying reactive airway disease worse and contributed to some mild reactive airway disease specifically with exertion.  Further testing was recommended.  

Pulmonary function studies dated 8 August 2007 revealed an FEV1 of 88% predicted post inhaler and an FEV1/FVC of 75%.  X-rays of the chest dated 20 August 2007 showed no active cardiopulmonary disease.  On 10 September 2007 the CI was treated with an Asmanex inhaler (mometasone, a steroid) prior to exertion.  Bronchoscopy was discussed as well.  On examination on 8 November 2007 respiration rhythm and depth were normal as were respiratory movements.  The lungs were clear to auscultation with normal breath and voice sounds.  No wheezing or rhonchi were heard.  At the 10 November 2007 NARSUM examination, the CI’s lungs were again clear to auscultation without rales, rhonchi, or stridor.  The examiner indicated the CI was unable to run without use of an inhaler (albuterol, an inhalational bronchodilator) but he was winded even with using an inhaler.  The CI could perform all duties, but deployment was uncertain; however, he could not run at full speed for at least 200 yards to take cover during an attack.  The examiner’s diagnosis was exercise-induced asthma and the CI was noted to have a 4T profile.  

Panel members had a very extensive discussion in regard to a fitness determination and noted the Air Force PEB, by considering the exercise-induced asthma a Category II condition, indicated the condition could be unfitting, but was neither unfitting nor separately not unfitting.  The panel noted the CI’s main restriction was running and questionable ability to deploy.  Because of the history of sinusitis, the feeling of a purulent or persistent nasal discharge as noted above, limited his running whereas he was noted to be unable to run without a bronchodilator, but was winded even with the use of one.  However, he was able to perform the duties of his Air Force specialty.  Furthermore, although he was treated, the record is limited in regard to follow-up of whether the medication was effective over time or was changed.  Therefore, because there was not a preponderance of evidence to substantiate overturning the PEB’s determination of exercise- induced asthma as a Category II condition, and there was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation, the panel was unable to find the condition separately unfitting.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended asthma condition, so no additional disability rating is recommended.

BOARD FINDINGS:  In the matter of the sinusitis condition and IAW VASRD §4.97, the panel recommends no change in the PEB adjudication.  In the matter of the contended asthma condition, the panel recommends no change from the PEB determination as a Category II condition.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends 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 20170227, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-01559.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

						Sincerely,

		

								XXXXXXXXXXXXXXXXXX
								Director
								Air Force Review Boards Agency

Attachment:
Record of Proceedings