RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02625
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060917

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Cannon Crewmember, medically separated for “neuralgia, involving left periauricular pain,” and “recurrent headaches,” rated 10% and 0%, respectively, with a combined disability rating of 10%.  

CI CONTENTION:  No specific contention was made.  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 Medical Evaluation Board (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 - 20060803	VARD - 20070110	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Neuralgia, Involving Left Periauricular Pain	8499-8405	10%	No VA Placement	
Recurrent Headaches	8199-8100	0%	Migraine Headaches	8100	30%	20070103	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  	

Neuralgia, Involving Left Periauricular (Ear) Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI had a history of eustachian tube dysfunction at age eight and underwent a left-sided tympanoplasty.  Left ear pain began in April 2004 after several ear infections.  An MRI showed mild mucosal thickening in the ethmoid air cells on the left, but was otherwise normal.  A CT scan of the temporal bones showed thickened retracted tympanic membranes, but was otherwise unremarkable.  Otolaryngology in July 2004, noted left eardrum tympanosclerosis (scarring) with a possible healed perforation posteriorly.  The CI had left ear pain with tympanic membrane retraction in August 2004.  In September 2004 there was tympanosclerosis of the left tympanic membrane with a thin monomeric membrane that was somewhat retracted.  There was no evidence of active inflammatory disease of the middle ear space.  The CI underwent laser occipital nerve block and two greater auricular nerve blocks in May 2005, but pain persisted.  In June 2005 otolaryngology noted bilateral retraction pockets and large adenoids.  MRI’s of the brain in October 2005 were unremarkable, while an MRI to evaluate trigeminal neuralgia showed no evidence of abnormality of the cranial nerves or brain, but there was thickening in the right sphenoid sinus consistent with inflammatory sinus disease.  

At an orofacial pain evaluation on 7 November 2005 the CI’s maximum distance between the upper and lower teeth was 54 mm (2.12 inches).  There was also left tympanic membrane retraction on the left and a right tympanic membrane perforation on the right.  There was no muscle tenderness in the facial or masticatory muscles.  At a follow-up visit on 8 November 2005, the examiner noted there was no clinical or radiographic evidence of the temporomandibular joints (TMJs) as the pain generator referring pain to the left ear; however, there were multiple caries (cavities) of the teeth.  Diagnostic anesthetic blocks of the left V2/V3 divisions of the trigeminal nerve and the greater palatine nerve failed to attenuate the pain despite profound anesthesia on the left.  The examiner felt the non-specific left otalgia was a “putative neuropathic pain” subsequent to multiple surgical manipulations of the left middle ear.  At a neurology clinic visit on 20 April 2006 the examiner noted the pain was periauricular and nerves to that area included the trigeminal nerve and the cervical plexus.  An MRI of the cervical spine was normal on 20 April 2006, as were MRAs (magnetic resonance angiograms) of the carotid and vertebral arteries and the brain.  

During the 28 April 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported a history of chronic ear infections.  Physical examination revealed left pre-auricular and post-auricular tenderness without erythema or edema.  The left tympanic membrane was retracted and there was a small perforation of the right tympanic membrane.  There was a scar of the left post-auricular area.  The 23 May 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of left periauricular pain and headaches (see below).  Physical examination showed the CI to be alert, oriented and in no acute distress.  Cranial nerves were intact as were sensation and motor strength.

At an otolaryngology clinic visit on 29 June 2006, it was noted that the CI had a tube placed in the left tympanic membrane that gave no relief and became dislodged.  There was no retraction on examination.  At a pain clinic visit on 30 June, examination revealed no tenderness of the scalp, cervical spine, trapezius muscles, mastoid or the thyrohyoid area, and there was no apparent TMJ dysfunction or swallowing abnormality.  Morphine was prescribed for the left ear pain.  

The 26 July 2006 MEB addendum, 2 months prior to separation, noted at the time of enlistment, the CI had an audiogram, which indicated hearing consistent with an H2 profile, which required a waiver for entry into service.  He underwent left pneumatic equalization tube placement in 2006, but noticed no difference in his symptomology.  The tube extruded and was not replaced.  He had no symptoms or sequelae of retraction and his hearing was unchanged in May 2006.  Examination showed intact tympanic membranes bilaterally without evidence of effusion.  There was minor retraction on the right and mild retraction on the left without evidence of current otitis media (middle ear infection).  The nose, lips, teeth, oral cavity and neck were normal.  An audiogram revealed an H1 hearing status with mild bilateral conductive hearing loss and no evidence of significant sensorineural hearing loss.  The examiner’s diagnoses were eustachian tube dysfunction and non-otogenic neuralgia of the left ear.

At the 3 January 2007 VA Compensation and Pension (C&P) neurological disorders examination, 4 months after separation, the CI reported headaches, but left-sided otalgia was not mentioned, although he noted pain began in the left temple region and spread.  The ears and left periauricular area were not mentioned as having been examined.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neuralgia involving the left periauricular 10%, analogously coded 8499-8405 (fifth (trigeminal) cranial nerve neuralgia-moderate, incomplete paralysis).  The VA did not list or rate the neuralgia involving the left periauricular condition.  The panel majority noted the etiology of the neuralgia of the left periauricular area was not determined despite extensive testing.  What was unusual is that even with anesthesia of the V2/V3 divisions of the trigeminal nerve, the CI still reported pain; however, at the C&P examination otalgia was not mentioned and the ears and left periauricular area were not addressed as part of the neurological examination.  Therefore, the panel had a difficult time determining the severity of the condition, which was subjective rather than objective.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority concluded there was insufficient cause to recommend a change in the PEB adjudication for the neuralgia of the left periauricular area condition.  

Recurrent Headaches.  According to the STR and MEB NARSUM, the CI’s headache condition began in 2000 on the right side of his head.  In May 2004, he complained of having a severe unilateral headache for 2 weeks with slight swelling of the right eye.  Treatment consisted of Maxalt (for migraine headache relief).  At an otolaryngology clinic visit dated 19 July 2004, the examiner noted that an MRI of the brain was negative.  The CI noted his headache started with throbbing in the area of the temple on the left.  During a clinic visit on 20 August 2004, the CI reported his headache resolved after one dose of indomethacin (nonsteroidal anti-inflammatory).  

On 20 October 2004, the CI reported two or three headaches a day for a week that lasted 5-10 minutes.  At a neurology clinic visit on 24 May 2005 the CI described a 10/10 left hemicranial (unilateral) sharp pain that began above the left ear/temporal area and radiated to the entire left side of the head with blurry vision and swelling of the left face, which no longer occurred.  He also had nausea, vomiting, photophobia, phonophobia and lightheadedness.  The headaches lasted 30 minutes to 1 hour and were relieved with sleep in a dark, quiet place.  Neurologic examination was normal.  He was on topiramate (headache preventative) and valproic acid (headache treatment) without relief.  The examiner’s assessment was migraine without aura.  Pamelor (for nerve pain) nightly was recommended for prevention along with Imitrex for acute, severe headache pain.  During the MEB examination, the CI reported migraines that started in April 2004.  The MEB NARSUM noted the complaint of headaches, which began on the right and progressed to the left side of the head.  Neurological examination was normal. 

At the C&P examination, the CI reported headaches, which he related to pain in the left ear, and reported two recent ER visits.  When severe headaches occurred, they were relatively incapacitating; others he worked through, but did have to stop working.  Physical examination and neurologic evaluation were normal.  The examiner’s impression was migraine headaches, mainly left sided, and he noted, “I think these are potentially disabling to him at times when it becomes extremely severe.”  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the headaches 0%, analogously coded 8199-8100 (migraine), citing prostrating attacks averaging less than one in 2 months over the last several months.  The VA rated the headaches 30%, coded 8100 (migraine), based on the C&P examination, citing characteristic prostrating attacks occurring on an average of once a month over the last several months.    The panel noted one reference from an otolaryngologist that the headaches were relieved with sleep in a dark, quiet place.  However, there was no mention of frequency.  Furthermore, the CI did not have a contemporaneous headache log to show the severity and/or frequency of the headaches or have ER visit documentation of headaches prior to separation.  The commander’s statement was silent about the frequency of the headaches.  Although the CI reported having two ER visits, he did not provide precise time frames for the visits, and those post-separation headaches, as severe as they might have been, did not occur while the CI was in the service.  The VA examiner thought the headaches were potentially disabling when extremely severe, but there was no mention of frequency.  Review of the STR did not show prostrating headaches occurring on average once every 2 months, or more frequently, over the last several months prior to separation to support a rating higher than the 0% adjudicated by the PEB.  After due deliberation, considering all 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 headaches.  

BOARD FINDINGS:  In the matter of the neuralgia of the left periauricular area and IAW VASRD §4.124a, the panel majority recommends no change in the PEB adjudication.  The single voter for dissent submitted the appended minority opinion.  In the matter of the headaches and IAW VASRD §4.124a, the panel recommends no change in the PEB adjudication.  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 20170315, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20190009843, 

Dear XXXXXXXXXXXXX:

	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. 

	A copy of this decision has also been provided to the counsel you listed on your application, Veterans of Foreign Wars (VFW), 204 West Main Street, Perryville, AR 72126.

Minority Opinion.  The minority voter noted the neuralgia of the left periauricular area was unremitting and not responsive to nerve blocks and multiple medications.  It was felt to be a “putative neuropathic pain” subsequent to multiple surgical manipulations of the left middle ear.  Even placement of a left pneumatic tube did not resolve the pain, but the tympanic membrane retraction noted by many examiners did resolve.  Therefore, because of the uncertainty of the etiology, recalcitrance to treatment, and inability to work, the minority voter felt that the neuralgia, albeit was not mentioned at the VA C&P neurological disease examination, was more consistent with severe than moderate.  While the neuralgia persisted unabated during service and multiple modalities were tried, but failed to relieve the pain, an understanding of the neuroanatomy is critical to understand how the pain could persist and defy treatment.  

“The lateral surface of the tympanic membrane receives sensory innervation from the auriculotemporal branch of the mandibular nerve, a branch of the trigeminal nerve (V3), the auricular branch of the facial nerve (CN (cranial nerve) VII), the auricular branch of the vagus nerve (CN X), and the glossopharyngeal nerve (CN IX).  The medial surface of the tympanic membrane receives sensory innervation from the tympanic branch of the glossopharyngeal nerve (CN IX).”  The cervical plexus (C1-4) and specifically C2 and C3 have sensory components that are located around the ear and at the lower part of the ear, while the V divisions of the trigeminal nerve provide sensory to the skin medial to the ear. Although the diagnosis of otalgia was raised, based on the severity of the symptoms, the pain had features consistent with trigeminal neuralgia (tic douloureux), although the C2 and C3 sensory components as well as the other nerves that innervate the ear were probably contributory to the genesis of the left otalgia and periauricular area.  Since there is no specific code for many of the aforementioned nerves, an analogous code for trigeminal neuralgia 8499-8405 is reasonable and appropriate and a 30% rating is not only warranted, but indicated IAW VASRD §4.124 (neuralgia, cranial or peripheral), which states:  “Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis.  However, the CI’s pain was neither dull nor intermittent, but was constant and more severe.  Therefore, a 30% rating is unequivocally supported by VASRD §4.124, which continues to state:  “Tic douloureux, or trifacial neuralgia, may be rated up to complete paralysis of the affected nerve.” herefore, the minority voter recommends the ROP and the Board Findings be modified as follows:

After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the neuralgia of the left periauricular area condition, coded 8499-8405.  

BOARD FINDINGS:  In the matter of the neuralgia of the left periauricular area condition, the panel recommends a disability rating of 30%, coded 8499-8405 IAW VASRD §4.124a.  In the matter of the headaches and IAW VASRD §4.124a, the panel recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Neuralgia, Involving Left Periauricular Pain	8499-8405	30%	
Recurrent Headaches	8199-8100	0%	
COMBINED	30%