Ray Cobb: 0:00

Love Talk Radio.

J Basser: 0:04

It's time for the Exposed Vet Radio Show. The Exposed Vet Radio Show, we discuss issues affecting today's veteran. Now here's your host, john M Ray.

J Basser: 0:17

Welcome, ladies and gentlemen, to the episode of the Exposed Vet Radio Show on this November 7, 2044. The Faux Red Radio Show on this November 7th 2024. It's 7 pm Eastern Time. I hope you pull up by the radio or by the computer stream or by the telephone and give us a good listen. Today we've got our number one guest on. Her name is Beth Explanenberg. She is the owner and operator of Valor for Vet, which is a company based out of Ohio and they do comprehensive, independent medical opinions for veterans in the business and the cleaning process. We've got Mr Ray Cobb. He's riding side subtle. Today We've got a real big horse here. How are you doing, ray?

Ray Cobb: 0:58

I'm doing great, doing great. Enjoyed the afternoon Good fall day down here, temperature about 75 degrees and clear skies. This is great. Enjoyed the afternoon. Good fall day down here Temperature about 75 degrees and clear skies this is great.

J Basser: 1:09

That's awesome. It's about 59 here today and cloudy and probably the same up there with the best thing kind of gloomy today.

Bethanie Spangenberg: 1:16

It sure is. Every time we do this podcast together it's raining.

J Basser: 1:23

Well, we need to get some sunshine and brighten your day right. For the past several months, guys bethany's been coming on. We've been discussing different areas of interest, from VA points, discussing DBQ, and today we're going to do start off. I don't't know how you want to start, but I think we're going to just get up a respiratory.

Bethanie Spangenberg: 1:49

Well, I think it's fitting. The sinus, rhinitis and other conditions of the nose, throat, larynx and pharynx. That's where we're starting for this DBQ. And I think it's fitting because it is the season for the winter, bugs and the cold and probably another few rounds of COVID coming through and I am also suffering from a sinus issue, so it's just fitting for the season and the weather and everything else. So hopefully it won't be, you know, too long here. It's a nine-page DBQ but we're only hitting on the major spots so it won't be nothing too overwhelming as we have seen some of these DBQs be.

J Basser: 2:36

Drag out, yeah, but it doesn't matter. You start where you want to start, all right.

Bethanie Spangenberg: 2:47

Well, I think it's important that we've talked about these DBQs. We've done quite a few over the last several months. Sinus and rhinitis is a big one. Once the burn pit and the presumptives kind of came in for particulate matter. We saw an influx of the sinus claims and the presumptives kind of came in for particulate matter. We saw an influx of the sinus claims and the allergic rhinitis claims and there's a lot of secondary conditions that can come from that. But the purpose of talking about these DBQs is really to lay out what the veterans should be expecting for their exam, helping them to familiarize themselves with what is in Q and what kind of questions that they should be prepared to answer when the examiner, you know, does their part. The other part of talking about these DBQs is nobody else is talking about them. So we're laying them out. We're talking about expectations from the medical expert side, what some of these things mean and, as I said before, the sinusitis and rhinitis is a big one, so it's nine pages and we're just going to dive right in.

Bethanie Spangenberg: 3:57

I've got it here in front of me. This particular DBQ was updated on September 5th of 2024. So that is you. That is just recent.

Bethanie Spangenberg: 4:09

The first page has an area where the medical examiner is to disclose their relationship to the VA and to the veteran, whether they're a VA health care provider or if they're regularly seen as a patient in their clinic. That's standard for all these DBQs. The first page also contains an area for evidence review and this is where the examiner talks about what evidence they have reviewed, either evidence that's in the claims file, or whether they're doing this as what they call an ACE, which we've talked about before. They're doing this as what they call an ACE, which we've talked about before, and sometimes those ACE exams don't require that records are reviewed or even that an interview is done. So providing your records to the VA before your compensation and pension exam is important. Also, on the first page start Section 1, which is the diagnosis, and we flip to Page 2, and it lays out specific diagnoses that are in this DBQ. And, as I always emphasize, you know, I just said this DBQ was updated a couple months ago and the very first box at the top of Page 2 is the veteran does not have a current diagnosed any claim condition. The reason I point this out is if you're going into your compensation and pension examination without a diagnosis, you're really hurting your claim and putting yourself at a disadvantage. That examiner can mark that box and never has to ask you any questions as far as the sinus portion, because they can review it, say well, they don't have a diagnosis, no examination indicated, they write their medical opinion and they can move on. That helps them in their numbers of turning a case over and their timeliness for any incentives that they may be receiving for their production numbers. So keep that in mind whenever you are applying for disability. You want to make sure that you go in with the current diagnosis.

Bethanie Spangenberg: 6:11

If we go down the list here, there's a few diagnoses on this list that we're going to talk about today, specifically chronic sinusitis, allergic rhinitis, non-allergic rhinitis. This is also known as vasomotor rhinitis. We'll talk about chronic laryngitis and we'll also talk about deviated nasal septum. Now these conditions are rated in the 38 CFR under Section 4.97. 38 CFR under section 4.97. And the bottom of page 2 is the section for section 2 for medical history, where it's a free text box. You tell your story and that medical examiner types away. Now, if we go to page 3, section 3, this is where the meat of all of the questions pertaining to the rating schedule start. Before we dive into page 3, are there any questions? As far as page 1 and 2 go, those are pretty standard. Just want to make sure we give a good stopping point before I jump into the meat of the DBQ SOP. All right, the DBQ.

Bethanie Spangenberg: 7:23

SOP. All right. So for Section 3, it starts off by asking the provider what sections they're going to be filling out for the exam. It wants them to designate which boxes or which specific set of questions that they're asking, based on the veteran's diagnosis. So if the veteran is claiming the chronic sinusitis, then the examiner can indicate that they're filling out the sinusitis section. Or if the veteran has allergic rhinitis, the examiner can indicate that they're filling out the rhinitis section. So that really just tells that rater what specific section they are filling out. On the DBQ section. They are filling out on the GBQ.

Bethanie Spangenberg: 8:10

So if we look, at part A, that is, the one that starts with sinusitis, on page three, sinusitis is more commonly known today as rhinosinusitis. Whenever we talk about the sinus cavity, it sits behind the nose, in your face. It also has pockets into, like above the eyes and deep into the skull, not quite towards the brain, but it's right in the middle of everything and it's really a filter, or serves as a filter, as we breathe through our nose. So while old terminology just said it was sinusitis, more recent terminology is rhinosinusitis, really acknowledging the role that the nose plays in sinus disease. And you can hear it in me oh, my goodness. Part A for sinusitis, they're asking the medical examiner to indicate the location of the sinus disease. Now I'm going to list off these names only because I want you to hear the terms. You're not going to be able to understand exactly where these locations are, but I want you to be familiar with the different areas of the sinus cavity to understand that there's more than one okay.

Bethanie Spangenberg: 9:27

So we have the maxillary sinus, we have the frontal sinus, the esmoid sinus, the sphenoid sinus and then they use a terminology called pan sinusitis, meaning that there is sinus disease in all the sinus cavities. So you as a veteran don't necessarily need to know where your sinus disease is located. That's really for the examiner to understand. You know, does the veteran's symptoms match up with this area of sinus disease? Or if it's indicated on a CT scan of the head, the radiologist will indicate the area of sinus disease. So it's really helpful for really matching up an individual's symptoms, not necessarily looking at treatment for a particular sinus. Okay, so again, like I said, the questions for this DBQ, they are not clinical questions, they are directed specifically to the rating schedule. We're trying to really narrow down what exactly the veteran is experiencing so we can relate it to the rating schedule and give a disability percentage. So if we look at question A2, does the veteran currently have any findings, signs or symptoms attributable to chronic sinusitis? And so the first box is chronic sinusitis detected only by imaging studies. So I briefly mentioned the CT scans. You could also capture some sinus disease on x-rays and a lot of times sinus disease can be found by accident. Let's say we're ordering a CT for the head or the brain and it will capture some of that sinus cavity and the radiologist may comment on sinus disease in a particular sinus cavity. And it's not necessarily something that the veteran may have symptoms of. They may have vague symptoms or seasonal symptoms, but the x-ray or the CT scan may pick it up. Incidentally, if that's the case, if a veteran's claiming the sinusitis disease and it's only captured by images and there's not really any type of criteria met for the symptom portion, the veteran would receive a 10% rating. If we move on to the next symptom capture, a 10% rating. If we move on to the next symptom capture.

Bethanie Spangenberg: 11:52

The next box is episodes of sinusitis followed by near constant sinusitis and the near constant sinusitis if it's paired with headaches, pain of the affected sinus, tenderness of the affected sinus or purulent drainage or crusting, that can actually give a veteran a 50% rating. Now if you read the CFR, the way it says is that you also have to have repeated surgeries. So you have that near constant sinusitis after repeated surgeries with headaches, pain and tenderness of the affected sinus and drainage or crusting. Now the M21 clarifies that no, the veteran can meet the criteria for the 50% without having repeated surgeries. They just have to have the symptom criteria of the headaches, pain and tenderness of the affected sinus and drainage or crusting. So that can be kind of confusing. If you're just looking at the 38 CFR, you can get a 50% rating for just those symptoms that appears to be, or is consistent with, a constant sinusitis. Okay, any questions about those two, the 10% and the 50% rating. That's in that first box there.

Ray Cobb: 13:08

No, Okay yeah no it's pretty clear to me.

J Basser: 13:15

Yep.

Bethanie Spangenberg: 13:15

Well, I do want to actually give the example that is in the N21. So, and actually you know I think I covered it. So if the veteran, for example, if the veteran has near constant sinusitis characterized by headaches, pain of the affected sinus, tenderness of the affected sinus and discharge or drainage, then they would qualify for the 50%. That's the example that they have in the M21. If we go on down to A3, question A3 tries to narrow down how many episodes of sinusitis and if they're incapacitating, they're incapacitating. So the VA defines an incapacitating episode of sinusitis is one that requires bed rest and treatment prescribed by a physician.

Bethanie Spangenberg: 14:16

Now, those incapacitating episodes. That requires bed rest is not something that you're going to go into the doctor and we're going to prescribe that bed rest. It's more that we're going to prescribe an antibiotic and recommend that you rest your body, not necessarily bed rest. Bed rest is viewed differently now than it did 30 years ago and so we know now that we have to keep you up and mobile as much as we can. So even if you are prescribed an antibiotic for sinus disease, we may not recommend the bed rest with it. We're going to say lower your activity, not necessarily stop activity. Does that make sense?

J Basser: 15:03

Okay, the bed rest has changed.

Bethanie Spangenberg: 15:05

Yes big time, especially when we look at things like back pain or back strains. The bed rest idea has really really changed for medicine, so incapacitating episodes of sinusitis characterized by headaches, pain and per or crusting from the sinuses. When I say perulant, that means that it's chunky, green nasty, pus-like drainage. Okay, perulant is a prettier word than pus or green nasty drained, so prurient is a prettier word to say. So they want the veteran to really look at the past 12 months and if the veteran has experienced anywhere between three and six episodes in the last 12 months, then that is a 10% rating. If they have experienced seven episodes or more in the last 12 months, that is a 30% rating. Now what I will say that I have seen is veterans will try to claim seven or more episodes but they don't necessarily have the medical records to match the seven or more episodes. The VA really wants to see medical treatment for those sinus conditions or sinus episodes. So if you are able to capture that, whether it's through a routine follow-up visit and you just happen to have a sinus flare-up causing the headache and the pain, you need to make sure that that's documented in the record so that you can use that as evidence to get that higher rating Okay?

Bethanie Spangenberg: 17:16

The next question talks about incapacitating episodes. So has a veteran had incapacitating episodes of sinusitis requiring prolonged treatment of antibiotics? And when they say prolonged they mean four to six weeks of antibiotics in the past 12 months. So they want to look okay after the over the last 12 months. How many episodes have you had where your doctor has prescribed four to six weeks of antibiotics? That today is absolutely unheard of.

Bethanie Spangenberg: 17:51

If you are prescribing an antibiotic for four to six weeks for a sinus infection as a clinician two, three times a year that is not caring for your patient. That is actually hurting your patient. That is not the standard of care now. So for you to capture that type of treatment or that type of episode, it may be difficult for you. If the veteran has experienced one or two incapacitating episodes that have required prolonged antibiotic treatment, One to two in the last 12 months gets 10%, three or more gets you 30% disability rating. So if we move on to A5, briefly going to mention it it asks about sinus surgery. If there is a particular type of sinus surgery, then you may qualify for different criteria. I'm not going to go really into that type of surgery because it is not common that we do radical what they call quote-unquote radical sinus surgery. In today's medicine, most of your surgeries that involve the sinus cavity are going to be endoscopic because of the technology, the cameras, the ability that we have in the surgery the operating room.

Bethanie Spangenberg: 19:23

Most of your sinus surgeries are going to be endoscopic, so that radical surgery rating criteria doesn't apply for most veterans, or I would say 99% of veterans. It does not apply to so let the holes in the nose.

Bethanie Spangenberg: 19:38

Exactly and to elaborate specifically on that, if the veteran has had radical sinus surgery and has continued infections in the bone following that surgery, they can get a 50% rating. That is not a good place to be. You don't want to be there. You don't want to try to shoot for that rating criteria, so don't for that rating criteria, so don't. Now, the last question for sinus is has the veteran had repeated sinus-related surgical procedures performed? Again, we're just trying to see where in that rating schedule you fit as it relates to the radical surgery or the endoscopic surgery, Before we move on to discuss the next section. The next section is rhinitis. They go hand in hand. One thing I should have done when we started talking about sinusitis is what does it mean really to have sinusitis? And I just assumed you know when people say they have sinus issues, you know, as adults, we probably understand what they mean because we've experienced it at some point.

Bethanie Spangenberg: 20:56

But by definition, sinusitis is an inflammatory condition of the sinus cavity. It can be caused by infections or environmental irritants. The most common cause of sinus infections are viral infections like the common cold, like you hear in my voice today. Now, sinusitis can cause because of the anatomy. This can cause because of the anatomy. If you get sinus inflammation, it can clog up or prevent appropriate drainage from the ear canals. Okay, excuse me, the ear tubes, ear canals, are what's on the outside. Ear tubes are what's on the inside, and we talked a little bit about this when we talked about vestibular disorders. We're talking, excuse me.

Bethanie Spangenberg: 21:49

We talked about the eustachian tube in the inner ear and how it functions. When the sinus swells it can block the tube inside the pressure valve of the ear and it can cause an inner ear infection. Okay, a lot of times when we have young children that have runny noses and sinus irritation and they end up with ear infections, that's the type of sinus irritation that I'm talking about can clog the drainage system and create bacteria overgrowth in the inner ear canal or inner ear tubes. Sinus disease or chronic sinus infections can cause headaches. They can actually cause chronic headaches With chronic sinus disease. It creates an irritation in the sinus cavity and in the drainage system and it actually lowers the headache threshold.

Bethanie Spangenberg: 22:55

Previously we've talked about how headaches occur. We have something that disrupts our regulation system, makes us a little more irritable and susceptible to developing headaches, and sinusitis or chronic sinusitis can be one of those things that triggers chronic headaches. Chronic sinusitis can be one of those things that triggers chronic headaches. Sinusitis can cause or aggravate sleep apnea because it is your upper airway system. The purpose of the sinus is to filter out the air that comes through our nose and down into our lungs, so that filtration system can be obstructed and blocked and either aggravate or cause sleep apnea.

Bethanie Spangenberg: 23:39

Sinusitis can also lead to meningitis because of the location of where the sinus sits, as it compares or as it relates to the brain and the cover of the brain what we call the brain sac or sac around the brain Because of the close location. If you develop bacteria overgrowth in the sinus cavity and your body is not able to get that bacteria under control or fight off that, that can lead to what they call translocation, that bacteria moves into the sac around the brain and can cause meningitis. That is not good. Unfortunately. I had firsthand experience with it recently and it's just wild how bacteria can behave at some points. Wild how bacteria can behave at some points. Additionally, uncontrolled sinus disease can actually aggravate asthma and it can aggravate COPD. So if you're thinking about whether or not your sinus issue is, kind of disrupting other parts of your body.

Bethanie Spangenberg: 24:48

You know those are some examples there that may contribute to your other conditions or may be aggravating your other conditions. Any questions there?

J Basser: 25:03

I had a friend that had that sign. He had a big sign of infection down in Bowling Green, kentucky, in the rural areas. Dad was a mayor of a small town and went to the Bowling Green Medical Center and they tested and he had it had turned into meningitis and he died.

Bethanie Spangenberg: 25:18

Now, that's very rare and I was surprised when.

Bethanie Spangenberg: 25:20

I, like I said I dealt with it a couple of weeks ago, no idea. The last place I thought that that infection would be affecting the brain was in the sinus cavity. So you know, for this particular individual, he had fallen and hit his leg like three or four weeks before this, and we knew he had an infection, didn't know where it was coming from. They did an X-ray of the leg, they worked up the teeth, they did a scan of the head and here it was. It was in the sinus cavity and that sinus infection actually created fluid around that, that eustachian tube in the ear, and so you can see the fluid buildup and it just wasn't, wasn't good. I was surprised. So it's not very common but it can happen what?

J Basser: 26:12

What controls that valve? Is that just something you yawn or something like that or do a dive check?

Bethanie Spangenberg: 26:22

or is that something that controls my nerves, my understanding and I? You know that's not really something I've thought a whole lot about. That's not my area of expertise I just the the.

Bethanie Spangenberg: 26:43

It's a pressure regulation system and I would assume that it's a nerve of some sort. But if that the sinuses, like I said, swell, it prevents the air from getting out of that inside ear pressure valve. So when you go on the plane and that pressure gets higher, that pressure valve, the eustachian tube, will try to regulate the pressure. So then that way there's not a pressure buildup. If you get pressure buildup in the ear you can actually start to develop tinnitus and it can become very painful. So when you have young children and they have ear infections and they can't regulate that ear pressure, they can actually tear the eardrum from that ear infection if the pressure can't get released.

J Basser: 27:30

That's why I put a lot of tape in kids.

Bethanie Spangenberg: 27:32

Yes we talked about this before. All right, so for time's sake we're going to jump into rhinitis. Rhinitis is an inflammatory condition of the nose lining. It can cause nasal congestion, runny nose, sneezing and itching. When we clinically look at rhinitis, we divide it into two types. We look at allergic rhinitis because allergic rhinitis is so predominant, and then we also look at non-allergic rhinitis. So allergic rhinitis is triggered by something that the individual is allergic to pollens, dust, mites, pet dander. It's an immune response in order to protect your body from those irritants. Non-allergic rhinitis is not an autoimmune process, but it is triggered by something that can irritate the sinus cavity or the nasal cavity, such as medications, hormonal changes, environmental irritants, like you're breathing in smoke and you bring it in your nose and it irritates the sinuses. And so what happens is the body releases moisture or mucus in order to get that irritant off the sinus cavity or outside of that nasal cavity.

Bethanie Spangenberg: 29:04

One other thing that causes a lot of what we call the vasomotor or the non-allergic runny noses is spicy foods. If you get a hold of a spicy food and it's just a little too hot that your body can't tolerate it, that whole system starts to water, you get watery eyes, your nose starts running. So a lot of people can appreciate that non-allergic runny nose when they eat spicy foods.

Ray Cobb: 29:33

Oh, you mean like jalapenos?

J Basser: 29:37

Yes, Cabernet will not be a little more powerful than rice.

Ray Cobb: 29:43

Yeah, oh, when I eat spicy foods, that happens to me all the time. I can't eat it. I'm allergic to it.

Bethanie Spangenberg: 29:52

I can't eat it, I'm allergic to it when we look at the DBQ on page 4, the DBQ questions are again specific to the rating schedule, not necessarily to the type of symptoms or the clinical application of the condition. So for rhinitis, your vasomotor or non-allergic rhinitis does not typically cause obstruction of the sinus cavity or the nasal cavity. But when you look at allergic rhinitis it typically does cause inflammation, swelling and obstruction. So when we look at the rating schedule, sometimes it may not apply if you have a non-allergic rhinitis. So the first question that's asked is there greater than 50% obstruction of the nasal passage on both sides due to rhinitis? You are likely to have inflammation on both sides if it's an allergic rhinitis. If it's a vasomotor or non-allergic rhinitis, you may not have any swelling of the sinus cavity, okay. Question B2, is there complete obstruction on the left side due to rhinitis? B3, is there complete obstruction on the right side due to rhinitis? Now, if you have complete obstruction on the left side or complete obstruction on the right side, that's a 10% rating. If you have 50% obstruction on both sides, that is a 10% disability rating. Question B4, is there permanent swelling of the nasal tissue? And B5, are there nasal, what we call polyps?

Bethanie Spangenberg: 31:49

Now, nasal polyps can develop over time due to a chronic rhinitis disease. They do not pop up and then disappear with something that happens over a short period of time. So those who experience a chronic allergy type of rhinitis may develop basically like skin tags inside the nose. You can't see these typically on exam. If they're seen on a physical exam by the examiner, that means that they are prominent. Normally the nasal polyps are visualized when they get a camera up their nose to check out what's going on or it's seen on a CT scan for imaging. So typically if an examiner is going to look in somebody's nose to see if there are nasal polyps, they may not always capture them.

Bethanie Spangenberg: 32:49

So if you're a, veteran that knows they suffer from allergic rhinitis, chronic sinus disease and you have a CT scan. Sometimes those are incidental findings. They don't pop up as an abnormality, they're in the fine details of the CT scan. You can use that and submit that to the VA to get a higher percentage. So if you have nasal polyps, let's see with nasal polyps you get a 30% disability rating.

Bethanie Spangenberg: 33:25

So just pay attention to some of the imaging that you get for your sinus cavity. So then that way you can really be aware of what you can optimize your rating for Now. The next question talks about a different type of rhinitis. It has to do with abnormal growth and abnormal cells, not very common at all. Not even going to spend our time talking about it. The one thing, a couple things to mention for both rhinitis and sinusitis. They are presumptive conditions if you've been exposed to quote unquote, fine, particulate matter and you served in Southwest Asia theater or in the Persian Gulf War on or after September 19th of 2001. So I bring this up because when the burn pits came out, or when they talked about the sand, and the air quality in Southwest Asia.

Bethanie Spangenberg: 34:27

Those are fine particulate matter and so if you have a sinus condition or allergic rhinitis condition, those are presumptive service connections, so you should be applying for those, okay. The one thing I also want to mention about this DBQ is that the C&P examiner, when you go to the exam, they may not say hey, do you experience headaches from your sinus condition? Do you have tenderness around your sinuses? What they may say is they may ask an open-ended question. They may say tell me about your sinus troubles, tell me about your sinus troubles. And if you don't hit these specific topics or these specific keywords, they may not ask you specifically and they may not mark that box.

Bethanie Spangenberg: 35:24

So if you are applying for sinusitis or rhinitis, you need to look at this DBQ and you need to look at these key words Headaches, tenderness of the sinuses, drainage crusting. You need to understand what kind of terms to use in order to properly express what you're experiencing with your sinus episodes. Okay, a lot of times a provider will just ask open-ended questions Tell me about this. They may not ask you specifically about how many episodes. You can put it on a note card and say well, I experienced a non-incapacitating episode from January 12th to February 7th. You can pull out your notes and talk specifically about what you're experiencing in order to capture what is actually happening. Okay, any questions about rhinitis?

J Basser: 36:30

No, I'll tell you a quick little. I'll tell you a quick little. We had a previous tech guy on the show. He did the recording stuff about two years ago. He actually passed away here a few years ago. He went for a CMP exam for rhinitis and renal conditions. He finally got his chart connected for it. But during the process of the CMP exam we said the guy had had his nose broken on several occasions. The last time he got it broken he was in a prison fight while he was in prison. The only problem was the poor guy never served a day in jail.

Bethanie Spangenberg: 37:08

So what yeah Sure did?

J Basser: 37:13

They said he got his nose messed up when he was in prison. He worked on the aircraft carrier, decked on a carrier, got all that grit and stuff you know, because the planes, the jet engine would blast off and all that nonstick stuff on the surface, all that goody sand stuff and the stuff that exhausts, yeah. So they said they got it while he was in prison because they kept breaking his nose. Got him to reserve a day in jail? Yeah, Of course they didn't tell him he had lung cancer either, until he had to go outside and he finally got his diagnosis. They told him one day that he had his lung cancer and the next day that there was nothing he could do for him.

Ray Cobb: 37:55

Wow, bethany, we've talked a lot. Everybody's pretty familiar with the burn pits. What about and John just mentioned it what about jet fuel? And John just mentioned it what about jet fuel? And some of the Air Force guys that are at the I forget what they call them that are at the end of the runway that you know, pull the pins for bombs and things and rockets when they're ready to take off and they get that big blast of dirt and sand and jet fuel and exhaust Ordnance.

J Basser: 38:35

Ordnance ma'am.

Ray Cobb: 38:37

Ordnance okay. Does that cause some of these sinus problems that we're talking about?

Bethanie Spangenberg: 38:44

Absolutely. Now I can say that from working in occupational health. Occupational health is on the job duties. You know we see patients that work in construction. We see all kinds of places where they breathe in these respiratory irritants, and jet fuels is absolutely a respiratory irritant. There's a lot of chemicals that we work with. There's a lot of fumes that we work with that can cause sinus issues and go on to develop chronic sinus issues. Now the difference between a veteran fighting a claim and the presumptive portion is that if the veteran doesn't see it as a presumptive condition, that would be something that you may need to get a nexus letter for. So in those instances, as a medical expert, I would want to understand where you were, how long you were there, for what type of activities you were doing, what type of symptoms you were experiencing when you were around these fumes or these chemicals that you can breathe in.

Bethanie Spangenberg: 39:46

And we actually have written some nexus letters. As it relates to jet fuels and the respiratory component or the respiratory irritation, those jet fuels are not good.

J Basser: 39:59

Guys, most of your jet fuels, if you're concerned out there, most of it's nothing but a different mixture of kerosene. So that's just. You know it's the same thing. You've got a kerosene heater in the house and you get that stuff all over you. That's what it is. Yep, ap-5 and 4.

Bethanie Spangenberg: 40:18

You know and we I think we've had it beat in our heads. I want to talk a little bit about smoke, just in general, from smoking. Okay, we talked previously that chronic smokers kind of have their sinus cavity coated and it gives them a little bit of protection from developing chronic sinus issues. But smoking not only has its direct effect. Okay, so if you smoke a cigarette you're breathing that stuff in. But what we don't really talk about is what they call a tertiary component, which is when those smoke and those particles get on the clothing and then later on we breathe those particles in from the clothing. They can be irritated and become particles into the air and then we breathe them in.

Bethanie Spangenberg: 41:11

We don't talk about that tertiary component a lot, but that tertiary component exists with smoking, with chemicals, with asbestos. That's why when you get it on your clothes, those clothes, you can't rattle those clothes because you're going to throw asbestos into the air. That's the same with all these other chemicals. Throw asbestos into the air, that's the same with all these other chemicals. Once they get on your clothing or that toxic substance gets on your clothing, you ruffle that clothing, you go, take your clothes off for the day and you don't properly wash your clothing, that chemical still lives on your clothing and you're breathing it in. So that's one thing we don't really talk about. When they try to educate you at the commercial about not smoking or chemicals, that and you're breathing it in. So that's one thing we don't really talk about. You know, when they try to educate you at the commercial about not smoking or chemicals, so it's just one thing that you really need to consider.

J Basser: 41:57

You know, in day-to-day life, Well, being a resident asbestos expert, I tell you that back in the 50s and 60s, maybe sometimes even the 40s, they were mining heavily in Africa. They were mining fossil towel Amish side is the best to know the stuff out of the ground. The workers would process it and mine it out of the ground and they would take it and they'd mill it. The people would go home from work, sit down on the couch and the kids would come and get in their lap and the mother would give them a kiss and the old dad would sit down and eat dinner.

Bethanie Spangenberg: 42:27

Yep.

J Basser: 42:28

Hundreds of thousands of people died because of that. The entire factory died, not just the workers, but the people that delivered the mail and everything. Wow, that's bad stuff, man. You also get the sinus cavity too.

Bethanie Spangenberg: 42:50

And you can develop cancers from those particles.

J Basser: 42:53

That's true. I mean it's just like a. It's just like. I mean it's got little sharp ends on it and it sticks to anything. You know. It sticks to your skin and your body will fight it for a while, but it's indestructible. And eventually it does turn into cancer. Yep, oh bad stuff. So I'm going to move on.

Bethanie Spangenberg: 43:16

oh yeah well, because they didn't have the, the protection. You know then, like they do now, the awareness then that they do now.

J Basser: 43:25

So even when they first started out in the early 80s with protection for the roof rods and things like that, they couldn't. They had the full force area, okay, but the mass and stuff they had for sampling was no good. It was one of the early 3Ms and they still hadn't made it through it, so of course they won't tell you that. All right.

Bethanie Spangenberg: 43:48

So I'm going to go ahead and transition into the next section, which is part C. I'm not going to dive a lot into it. It has to do with what they call the larynx and the pharynx. So it's the vocal cords, your voice box and basically the very back portion of your throat, basically the very back portion of your throat. If you open your mouth and you look in your mouth, it's behind your uvula, your little boxing bag that's in the back of your throat. There it's behind that. That's your pharynx.

Bethanie Spangenberg: 44:19

Okay, there's not a lot really to understand as far as anatomy goes. The layman phrases that we use is our vocal cords and we know that when we develop laryngitis we know that our vocal cords are irritated. So just going to briefly talk about laryngitis as it falls on the rating schedule. Laryngitis is inflammation of the voice box that can cause symptoms of hoarseness, loss of voice and throat discomfort. As you hear me now I am experiencing all those things. Laryngitis is commonly caused by viral infections, which I think I got from my children, and irritation of the vocal cords. Vocal cords, irritation of vocal cords can be caused by mucus, smoke inhalation, chemical inhalation, smokeless tobacco. If you're a chronic dipper snuff, it can irritate your vocal cords and cause laryngitis. And even if you have heartburn or reflux that's uncontrolled that stomach acid can irritate your vocal cords and cause chronic laryngitis issues. Now if you get service-connected for chronic laryngitis, you get a 10% rating for hoarseness and with inflammation of the vocal cords or the mucous membranes around the vocal cords.

Bethanie Spangenberg: 45:52

In order to visualize the vocal cords, you have to take a scope down and look, and if an individual is diagnosed with chronic laryngitis, you should be seeing specialists for them to look at your vocal cords seeing specialists for them to look at your vocal cords. The reason I say this and emphasize this is that if you have hoarseness or laryngitis that persists more than two weeks, you need to talk to somebody about it. I have firsthand experienced patients who've had chronic laryngitis. I would refer them to a specialist and they would find a tumor or a cancer either on or around their voice box, affecting their vocal cords and causing laryngitis.

Bethanie Spangenberg: 46:43

So if you're a veteran, you know you've been a smoker, you know you drink alcohol, you have uncontrolled reflux, that hoarseness isn't going away you need to talk to somebody about it so they can look and make sure that you don't have something there. Early detection, your outcome is better. Okay, so just keep that in mind. For chronic laryngitis, a 30% rating means that the veteran is experiencing hoarseness, with thickening of the vocal cords, they may have polyps or the pre-malignant or pre-cancerous changes on the biopsy. So again, just emphasizing that if you catch it early, your outcome is better emphasizing that if you catch it early, your outcome is better.

J Basser: 47:35

What's the difference between laryngitis and pharyngitis?

Bethanie Spangenberg: 47:38

There is, it's just the location. So the pharyngitis is when you have that really fire feeling on the roof of your mouth and it makes it nearly impossible to swallow. So when you go to swallow and the back of your throat is really burning, that is the irritation of the pharynx. It is the like I call them the voice bubbles, or what I'm experiencing, that is the laryngitis. When you talk, your vocal cords clap together and they should be making a fine seal in order to control the air for your voice. With laryngitis, you get irritation of those vocal cords and so they're not creating the seal for the air movement like they should, and so you'll get those the crackles and the pops when you start to talk, because that seal is not being created like it normally would.

Bethanie Spangenberg: 48:34

Your pharyngitis is what prevents you from swallowing. That's the like. If you have ever experienced strep throat or even mono, you get this rapid throat pain. You get this rapid throat pain when you experience like post-nasal drip from allergies or allergic rhinitis or sinusitis in the back of your throat that's more of a slow progression of a sore throat that you're experiencing, besides the pharynx being irritated.

Bethanie Spangenberg: 49:08

Does that help? Of course, the voice box is a little bit lower than the pharynx, location-wise, so if that also kind of helps understand where each one's located, so, I'm going to jump to page five.

Bethanie Spangenberg: 49:29

Page five covers conditions of the pharynx and the larynx that are not common, and so I'm going to go ahead and jump to page six. Really, the biggest one that I want to hammer home for the next one, I guess for this DBQ is part D and that is the deviated nasal septum. We get a lot of veterans that ask about getting service-connected for a nasal septum deviation and so we get a lot. Like you said earlier, a lot of the trauma to the sinus cavity and the deviated septum is rated similar to the sinus and the rhinitis conditions. So question one is is there at least 50% obstruction of the nasal passage on both sides due to traumatic septal deviation? I will tell you that having obstruction on both sides is not common, because normally when you get a broken nose, that's where the deviated nasal septum comes from. It's going to be a crooked nose. It's not going to smash you straight on, it's not going to squish you to where you get 50% obstruction on both sides. You're usually going to have that nasal septum kind of crooked. The nose looks crooked If you look up in the mirror at the bottom of where your nose meets your lip, that is your septum, the skin over the septum, so you can look at it and visualize that it may be crooked. Or you can look at the external part of the nose and see that it's crooked, but you're not normally going to get a smashing type of trauma whenever you break your nose. A 10% rating is given if there's 50% obstruction of the nasal passage on both sides. A 10% rating if there is complete obstruction on the left side, a 10% rating if there's complete obstruction on the right side. Again, your deviated septum is not normally going to be a 50-50 on each side. You're just going to have a crooked nose and it creates either like a 90% obstruction and like a 10% obstruction on the other side.

Bethanie Spangenberg: 51:46

Most people who've experienced broken nose they're like you know, I could really breathe really well to my left side, but my right side I can't really breathe out of. That's typically the history that we get for nasal trauma. And when I talk about nasal trauma, I also want the veteran to consider okay, if you broke your nose in service, somebody hit you in the face, they kicked you in the face, they broke your nose, but did you also lose consciousness? Because a lot of times clinicians will say, oh, you broke your nose, but they won't ask you about TBI type symptoms. Did you lose consciousness? Do you remember everything that happened?

Bethanie Spangenberg: 52:26

And a lot of your TBIs come from hits to the face, and so if you're a UFC fan, you can see a lot of TBIs that come from getting hit in the face, but a lot of veterans don't think about that. I had a veteran who he was actually kicked in the jaw and they broke his jaw, but he was also flat on the ground when that happened, so he had a TBI when he was kicked and so he didn't think about filing for the TBI. He just filed for the broken jaw and it's like well, trauma to the face, trauma to the head. You also need to think about a TBI is because if you have a traumatic broken nose, were you conscious the whole time? Did you also have a TBI? Are you experiencing symptoms of a TBI?

J Basser: 53:23

So just think about those when you're filing for your claims.

Bethanie Spangenberg: 53:26

How much longer do we have.

J Basser: 53:31

I can actually summarize it here in a few minutes. Page six We've got a caller.

Bethanie Spangenberg: 53:35

Go ahead. Okay, I'll be quick. Page six it talks about tumors and neoplasms, which they do in every DBQ, and we'll talk about that in another show. Page seven what is important here is that it prompts the examiner to conduct any type of scar exam if it's indicated, and we've talked about the scar ratings and what that means.

Bethanie Spangenberg: 53:58

The last one that I think is important is page 8. It talks about the diagnostic testing and we talked about the nasal polyps that give you that extra rating. It's likely going to be seen on a CT scan or an endoscope, but not necessarily on a physical examination. So you need to be looking at your imaging results and, additionally, if you've had an endoscope where they take the camera in, there is a procedure note that the specialist will write up. It'll talk about what the sinus cavity look tissue looked like, whether they saw nasal polyps or obstruction, and that is valuable evidence that you can use to support an increase in your claim and I highly encourage you to get that endoscope procedure test results to submit. And then the last page is the functional impact which you should be putting in your statement and supportive claim, and then, finally, the examiner certification and signature and that is it.

J Basser: 55:06

Good deal. Okay, I'll see you guys, you said we had a dollar? Yeah, we do. It's the guy to what we talked about him earlier and he's got his hand up why it man?

J Basser: 55:28

you're like you're going live, hello community, fine, yes, right, yeah, you mean just explain the situation. Or she Hello, can you hear me? Fine, yes, go ahead. Yeah, you mean just explain the situation. She knows that it's a DIC issue and things like that, and you're talking about the valve issue versus a supporting artery disease. Yeah, I'm considering. I'm already service-connected for artery disease and I put in for a valve claim about a year ago and was denied, and I'm thinking about appealing it with an IMO. And is it something that I should do for DIC purposes or am I covered for any heart disease-related issue because of the artery disease, or what's your opinion on that as far as DIC and heart conditions?

Bethanie Spangenberg: 56:28

So most people have issues with coronary artery disease that cause their death or demise. If your valve disease is significant enough, a couple things can happen. If the coronary artery disease or the coronary arteries around the heart are so severe, it can cause the valves to fail.

Bethanie Spangenberg: 56:52

Or if the valves are so diseased it can cause the heart to fail. Or if the valves are so diseased it can cause the heart to fail. The only way to really know the status of the heart function is to see an ultrasound of the heart. That ultrasound of the heart will tell me where the heart valve disease is and is there heart failure or decomposition, meaning the heart is not working as well in that study.

Bethanie Spangenberg: 57:22

So if the valve disease is mild, and it's not affecting the heart function or how it squeezes, there may not be value in pursuing it. I would be happy to look at it and, if you don't mind, maybe on the next show. We can kind of talk about what we found and maybe open the case up a little bit more for a discussion, so there may be value. It would be. I'd have to see what your ultrasound looks like and what your testing looks like.

Ray Cobb: 57:48

Okay.

J Basser: 57:52

All right. How would I get that information to you? Just contact the number or something.

Bethanie Spangenberg: 58:00

Yes, I will talk with John at the show and we'll try to get information exchanged so we can get that material over to me. Okay, Thank you. Did my explanation make sense?

J Basser: 58:20

Yeah, yes, it sounds like you're saying it depends how serious the valve disease is. If it's mild, then it's probably not worth pursuing. Is what I heard. Is that correct?

Bethanie Spangenberg: 58:32

Right. Yeah, that's correct. So we just really got to look and see where the status of everything is or see if it's worthwhile. I agree with you trying to do what you can to capture those service connections. In the event, you do pass away from something like that. I think that's smart and you're thinking ahead of the game.

J Basser: 58:51

Well, I had the mitral valve issue for years and the artery disease is just something recently that's come into play. So the valve issue, I've had it for years.

Bethanie Spangenberg: 59:11

Okay.

J Basser: 59:12

So the artery disease didn't cause the valve issue?

Bethanie Spangenberg: 59:17

I wouldn't think anyway, we also have to look at it. Did the artery issue aggravate the valve issue? That echo will tell me a little bit more about your story, okay, so what is?

J Basser: 59:33

the individual basis, Individual basis, this. Everybody is not the same. So this is the individual basis, Correct. Once he sees the echo. Once he sees the echo, he'll know that can be it. Do you want the actual echo or do you need to report, bethany?

Bethanie Spangenberg: 59:52

Just a report. Just a report, okay, okay.

J Basser: 59:53

Just a report. Just a report, okay. Okay, we'll teach him how to do the portal and how to upload something to you. Okay, betsy.

J Basser: 1:00:10

Okay, no problem, no problem, no problem. It's like you got that out and you're feeling bad. It's a bit of a heck of a job it sounds, you know. I mean you got a little bit of you, got a little bit learned at the end of there, you know, you tell you have a little draining stuff going on in your nose, but I'm glad you're doing better.

J Basser: 1:00:40

I'm going to check on Mr Cripps, james, how you doing? Buddy, I'm doing good. John, I might have threw another one. Buddy, you're lucky man. Well, I think somebody's riding on my shoulder too. I talked to you Friday. I thought for sure you'd be doing dial shoulder too. I talked to you Friday. I thought for sure you'd be doing dialysis Monday morning. I tell you what. I'm glad you didn't. I was supposed to be on dialysis, I just dodged another bullet. You don't get scared like that man. But man, I'm happy to be back, I'm good to go. I'm minus a couple toes and parts of my feet, but heck, I got extra parts anyway. Why, remember? Was it Johnny Cash that sang that song? He worked at a Cadillac plant and by the time he retired he had no parts to build a Cadillac plant, and by the time he retired he had enough parts to build himself a Cadillac in his house.

J Basser: 1:01:40

I'm about 80% aftermarket parts at this point.

Ray Cobb: 1:01:47

He's Troy built. I think is that what you said You're Troy built.

J Basser: 1:01:51

Well, you know, if you've got aftermarket parts, they're replaceable. Well, you know, if you've got aftermarket parts, they're replaceable. Well, I don't like saying this to a lot of Vietnam. Best get mad at me, you, Heinz 57. Well, you know, I can laugh about it, but for the last two months I hadn't been laughing about it. I tell you it's been rough. Wouldn't want anybody else to experience that kind of thing. But let me put the word out there, man, if you wear AFOs, if you wear foot braces, wear them.

Ray Cobb: 1:02:33

I left mine off for about two weeks and that's what's caused all of my trouble.

J Basser: 1:02:37

I was giving my legs a rest when actually I condemned them. That's important, yep.

J Basser: 1:02:42

But, anyway, it's really good to be back. Well, it's good to hear your voice, buddy. You sound good too. Last time I talked to you you sounded real weak and now you sound a lot stronger. Yeah, I was really getting weak. I was a whole lot sicker than I thought I was at the time. If it would have been 20 more feet to the emergency room door, I don't think I would have made it. Yeah, okay, well, listen, guys. The only thing. Thank you for coming on. I appreciate you very much. You're always a birth of fresh air, and we'll do this again in December, and then we'll do it again in January and February Did you want to talk about your special show on Monday.

J Basser: 1:03:32

Yeah, guys, we're going to do a special show on Monday. It's actually already recorded. We've got a show. It's in the queue for Mr Bill Robinson. He's the longest-held enlisted prisoner of war in the Vietnam War and a very emotional show, one of the best we've ever done. Ray did a good job too in the show and Bill's a good speaker and just listening to just them talking to him will open your eyes up and especially how you know the VA doesn't treat everybody the same.

J Basser: 1:04:03

I'm serious, but if it happens for seven years and they message you like that, that's not good. You agree, ray?

Ray Cobb: 1:04:11

I agree 100%, he deserves a whole lot more than what they ended up doing.

J Basser: 1:04:17

And.

Ray Cobb: 1:04:18

I know he's very bitter about the VA, just like a lot of us are. And hopefully we can convince him to take action and let's see if we can't get him what he deserves Seven and a half years in captivity in a three by five cell a lot of times serving, I would say, more than half of it, or 80% of it in solitary confinement, and sometimes after being beaten to be tied up. You just got to hear his story. You just got to listen to the story.

J Basser: 1:04:57

Yeah, give a good listen folks. It's an amazing show. I'll be there Monday. Ray will be there Monday. So the more people listen, the better off, the more you'll be.

Ray Cobb: 1:05:07

What's the time, John?

J Basser: 1:05:09

At the same time, jim will be at 7 o'clock. Okay, ray, if I can help Bill in any way, let me know.

Ray Cobb: 1:05:17

We'll do it. We'll do it. I know you've met him before and actually got to sit down and visit with him one night when you and he both were visiting here in Winchester. So he's a big guy. I mean this isn't a little. I mean if he was a normal-sized guy I'm not sure he could have made it, but I think he's about 6'3" a big guy and you just got to hear his story and guys. You know, I'm glad I never had to think of the things that he did. It's just amazing.

J Basser: 1:05:56

Well, I tell you guys my lifetime I mean, I've been around the world a few times. I've met a lot of famous people. In my lifetime you know Kind of like Ray's interviewed famous people, but I've actually been there with a lot of famous actors and things like that. This guy, ray, is right up there with them. As far as you know people, we've met some of the people you talk to. It's going to be a really good show. Listen, I'm going to go ahead and shut her down. It's Thursday night and it's cold outside. I hope it warms you up some and we'll see you guys Monday and then again next Thursday. We're going to have the one and only John Doley on you guys and Bethany. Thank you for coming on, young lady. We do appreciate you.

Bethanie Spangenberg: 1:06:35

Thank you, I appreciate you.

J Basser: 1:06:37

If you need anything, you can reach out and text me. I'm only 270 miles or seven digits away. All right, Guys, we thank you all for listening. I'm going to go, just shut her down. We don't need to play an extra tonight because we're over anyway. So thank you all very much. We appreciate you.

Bethanie Spangenberg: 1:06:57

Thank you, have a good night.

Ray Cobb: 1:06:58

Good night guys.

Bethanie Spangenberg: 1:06:59

Bye, bye.

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