Citation Nr: 0001080 Decision Date: 01/13/00 Archive Date: 01/27/00 DOCKET NO. 97-31 320 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to service connection for deep venous insufficiency of the left leg, to include service connection secondary to service-connected Sjogren's syndrome. 2. Entitlement to an increased evaluation for Sjogren's syndrome, currently evaluated as 60 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant and an acquaintance ATTORNEY FOR THE BOARD L. Jennifer Lane, Counsel INTRODUCTION The veteran had active service from July 1973 to September 1986. The current appeal originated with a rating decision dated in September 1996 in which the Regional Office (RO) denied service connection for deep venous insufficiency of the left leg secondary to Sjogren's syndrome and granted a 60 percent evaluation for Sjogren's syndrome, effective in March 1996. The veteran subsequently perfected an appeal of that decision; and a hearing was held at the RO in June 1999 before the undersigned, a member of the Board of Veterans' Appeals (Board). FINDINGS OF FACT 1. All relevant information necessary for an equitable disposition of the appeal has been developed. 2. No competent medical evidence is of record that would establish that the veteran currently has vasculitis which is causally related to service or to any incident or event therein, or which shows that such a disability is etiologically related to his service-connected Sjogren's syndrome or has been aggravated by that service-connected disability. 3. No competent medical evidence is of record that would establish that the veteran currently has deep venous insufficiency of the left leg which is etiologically related to his service-connected Sjogren's syndrome or has been aggravated by that service-connected disability. 4. The veteran has deep venous insufficiency of the left leg which had its onset in service. 5. The veteran's Sjogren's syndrome is not productive of constitutional manifestations associated with serous or synovial membrane or visceral involvement or other symptom combinations which are totally incapacitating. 6. The veteran's Sjogren's syndrome is not productive of frequent exacerbations which produce severe impairment in health. 7. The veteran's Sjogren's syndrome is not productive of compensable limitation of motion of any affected joints; any compensable impairment in visual acuity; more than moderate hoarseness and moderate inflammation of the mucous membranes; more than moderate incomplete paralysis of the seventh cranial nerve; more than severe incomplete paralysis interfering with sensation in the mucous membranes due to dry mouth; more than moderate incomplete paralysis interfering with sensation in the mucous membranes of the nose; more than slight disfigurement on the left side of the head; and no more than moderate disfigurement on the right side of the head. CONCLUSIONS OF LAW 1. Vasculitis was not incurred in or aggravated by service; nor is such disorder secondary to the veteran's service- connected Sjogren's syndrome. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.310 (1999). 2. Deep venous insufficiency of the left leg is not secondary to the veteran's service-connected Sjogren's syndrome. 38 U.S.C.A. §§ 1110, 1131, 5107; 38 C.F.R. § 3.310 (1999). 3. Deep venous insufficiency of the left leg was incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 4. The criteria for an evaluation in excess of 60 percent for Sjogren's syndrome are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, Diagnostic Codes 6350, 6516 (1996); 38 C.F.R. §§ 4.2, 4.7, 4.10, 4.20, 4.25, 4.40, 4.45, 4.59, 4.71, 4.84a, Part 4, Diagnostic Codes 5206, 5207, 5208, 5213, 5260, 5261, 6350, 6516, 7800, 7819, 8207, 8209 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Deep Venous Insufficiency of the Left Leg Initially, in light of evidence discussed below, the Board finds that the veteran's claim for entitlement to service connection for deep venous insufficiency of the left leg is well-grounded within the meaning of 38 U.S.C.A. § 5107, that is, the claim is plausible, meritorious on its own or capable of substantiation. Murphy v. Derwinski, 1 Vet. App. 78 (1990). The Board further finds that the Department of Veterans Affairs (VA) has met its duty to assist in developing the facts pertinent to the veteran's claim. 38 U.S.C.A. § 5107. The Board also notes that entitlement to service connection for a particular disability requires evidence of the existence of a current disability and evidence that the disability resulted from a disease or injury incurred in or aggravated during service. 38 U.S.C.A. §§ 1110, 1131. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, secondary service connection for a disability is warranted when that disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Secondary service connection is also warranted for a disability when that disability is aggravated by a service- connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). The veteran testified at the Board hearing in June 1999 that he was first diagnosed with venous insufficiency of the left leg while in the Air Force. According to a service medical record dated in November 1976, the veteran had recurrent erythematous macular eruptions over the lower legs and dorsum of the feet which faded after a couple of days into brownish macular lesions. It was also noted that the eruptions had previously faded away completely but that the brownish lesions had persisted with occasional spread over the knees and onto the thighs with associated edema and stiffness of the knees and ankles over the previous few years. A service medical record dated in January 1981 shows that an examination of the veteran's extremities revealed stasis dermatitis involving both lower extremities. The veteran was referred to the dermatology department. It was noted that the veteran first noticed irregular crops of red eruptions on his lower legs at age twelve. The assessment was a skin condition associated with Sjogren's syndrome. The veteran was hospitalized in March 1981. At that time, examination revealed changes which appeared to be stasis dermatitis over both lower extremities, and the examiner described such changes as very extensive, especially considering the veteran's age. The initial impression was dermatological changes over the lower extremities, possibly stasis dermatitis. According to the hospital record, the veteran was sent to the dermatology clinic where it was felt that he had a pigmented purpura, probably hyperglobulinemia purpura, associated with Sjogren's syndrome; however, cryoglobulin tests were negative. The veteran was hospitalized again in July 1986. At that time, examination revealed a small healing ulcer in the right medial aspect of the ankle and what appeared to be some hemosiderin type changes bilaterally in the lower distal extremities. There was no diagnosis which specifically referred to either of the lower extremities. Service hospital records dated in August 1986 show that there were bilateral purpuric lesions on the lower extremities with a 1 cm. squared resolving medial ulceration of the right medial pretibial area. A right venogram was normal. The final diagnoses did not include any reference to the lower extremities. The Board will also summarize the medical evidence pertinent to the current claim since service. A VA hospital discharge summary dated in October 1989 shows that the veteran underwent debridement and split thickness skin graft of the left medial calf. According to the hospital summary, the veteran presented with a chronic, nonhealing ulcer of the medial aspect of his left calf which had developed following a traumatic injury to the mid shin area two years prior to admission. The ulcer had progressed to a shallow ulcer, which had basically waxed and waned in size, but had never completely healed. It was noted that the veteran also had some element of venous stasis and that his wound worsened when his lower extremity was placed in a dependent position for extended periods of time. The diagnoses at a VA examination performed in November 1989 included ulceration of the lower left leg, treated satisfactorily at this time by split-thickness graft, possibly related to Sjogren's syndrome. A May 1990 VA outpatient treatment record shows that the veteran had a lower left leg ulcer diagnosed as venous stasis with history of Sjogren's. Another VA outpatient treatment record dated in July 1990 shows that the veteran had Sjogren's and had had a problem with vasculitis. At that time, the veteran was being treated for an ulceration on the mid lower left leg area. A private medical record dated in November 1995 shows that the veteran had a venous stasis ulcer over the medial aspect of his left ankle. The report of a private medical examination in January 1997 shows that examination of the extremities revealed that there were changes of venostasis; and the impression was Sjogren's syndrome, history of non-Hodgkin's lymphoma and new parotid swelling. The veteran has submitted excerpts from medical texts and information from Internet web sites that show that Sjogren's syndrome can affect blood vessels. Those materials also show that patients with Sjogren's syndrome may develop vasculitis and that the skin is the most commonly affected organ. The evidence of record includes the results of a private medical examination in November 1997, at which the examiner specifically addressed the issue of whether the veteran had vasculitis. The examiner reported that there was no evidence that the veteran had ever been truly diagnosed with vasculitis. Examination revealed bilateral lower extremity evidence of venostasis. Also, the report of that examination includes an assessment of stasis dermatis without any evidence of active vasculitis. Additionally, the examiner related: We had a long discussion with the patient that we feel that there is no active vasculitis. We told the patient that he is correct that there is a large number of patients that will develop vasculitis secondary to Sjogren's, but he does not have a vasculitis at this time. We cannot say that this patient ever had a vasculitis, as he would like us to corroborate today, as there is just not sufficient evidence to prove this. We informed the patient that we could send a letter to [J.H.] in the Veterans Service stating that patients with Sjogren's may develop vasculitis, but as stated above, we do not have any evidence that the patient has a past history of vasculitis, and he certainly does not have vasculitis today. Thus, there is probative medical evidence against finding that the veteran has vasculitis due to service-connected Sjogren's syndrome; and there is no competent evidence that the veteran had vasculitis in service, that he has vasculitis which has been aggravated by Sjogren's syndrome, or that he currently has vasculitis. The veteran also asserts that he has deep venous insufficiency of the left leg due to his service-connected Sjogren's syndrome. The evidence of record includes medical evidence which specifically addresses whether the veteran has deep venous insufficiency of the left leg and the relationship of that disorder to the veteran's service- connected Sjogren's syndrome. A VA examination of the skin in April 1996 revealed some evidence of leg distention with some stasis dermatitis. It was noted that Doppler studies of the left leg showed left deep venous insufficiency. The final diagnosis was left deep vein insufficiency. The report of a VA examination for systemic conditions performed in April 1996 includes a diagnosis of deep venous insufficiency of the left leg. According to that examination report: Regarding the skin changes and the ulceration on his leg, it would appear that this most likely is due to his venous insufficiency rather than having any relationship to Hodgkin's, Sjogren's syndrome or chemotherapy, as these three conditions apparently all arose at the same time, either shortly before or shortly after discharge. It would be difficult to rule out the possibility of enlarged groin nodes having an adverse effect on venous return in the left lower leg which could set up a phlebitis or vein insufficiency; however, the veteran does not apparently allege this. While the lymphoma can be connected to the Sjogren's syndrome, it would be difficult with the present information to connect the venous insufficiency to this. It should be noted with his veins that there were no distended veins in evidence which would be necessary for the performance of the Perthes or the Trendelenburg tests. Thus, while there is competent evidence that the veteran currently has stasis dermatitis, there is competent medical evidence against finding that stasis dermatitis is due to the veteran's service-connected Sjogren's syndrome. Moreover, there is no competent evidence tending to show that the veteran's current stasis dermatitis was caused by or has been aggravated by the service-connected Sjogren's syndrome. As discussed above, there is competent evidence contemporaneous with service which shows that stasis dermatis was present during service, the service medical records, and there is competent evidence that such disorder is currently present, the report of the April 1996 VA examination. Also, according to Dorland's Illustrated Medical Dictionary, 452 (27th ed. 1988), stasis dermatitis is due to venous insufficiency. Additionally, medical evidence dated after service relates skin changes and the ulcerations on his left leg, which were also manifested throughout service, to venous insufficiency. Moreover, while there is no specific medical opinion tending to link the stasis dermatis present now to the stasis dermatitis present in service, he was treated for stasis dermatitis on more than one occasion in service and ulcers of the left lower extremity shortly before his separation from service and on more than one occasion since service. While a January 1981 service medical record shows that there was stasis dermatitis of the legs, a dermatological examiner's assessment was a skin condition associated with Sjogren's syndrome and it was noted that the veteran first noticed irregular crops of red eruptions on his lower legs at age twelve, the veteran's enlistment medical examination in July 1973 included normal clinical evaluations of the lower extremities and skin. Moreover, there is no competent evidence, and thus clear and unmistakable evidence, that deep venous insufficiency of the left leg existed prior to service. Therefore, the Board does not find that the presumption of soundness has been rebutted in this case. 38 U.S.C.A. §§ 1111, 1137 (West 1991). In light of the evidence discussed above, the Board finds that the pertinent evidence currently of record is in equipoise as to whether there is a reasonable basis for concluding that the veteran's current deep venous insufficiency of the left leg had its onset in service. Additionally, it is felt that to further delay reaching a final decision on the appeal of the claim in question by remanding in order to try to obtain additional evidence would not be in the best interests of the veteran. Therefore, resolving doubt in the veteran's favor, the Board finds that deep venous insufficiency of the left leg was incurred in service. 38 U.S.C.A. § 5107(b). Finally, with regard to the reference to Dorland's Illustrated Medical Dictionary, as the information obtained from that source was used in granting benefits, the Board finds that any violation of Thurber v. Brown, 5 Vet. App. 119 (1993), is not prejudicial to the veteran. II. Sjogren's Syndrome The Board finds that the claim for entitlement to an increased evaluation for Sjogren's syndrome is well-grounded within the meaning of 38 U.S.C.A. § 5107, that is, the claim is plausible, meritorious on its own or capable of substantiation. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The Board further finds that the VA has met its duty to assist in developing the facts pertinent to the veteran's claim. 38 U.S.C.A. § 5107. Disability ratings are based on schedular requirements which reflect the average impairment of earning capacity occasioned by the state of a disorder. 38 U.S.C.A. § 1155. Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. In determining the level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records. 38 C.F.R. § 4.2. An evaluation of the level of disability present must also include consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment, and the effect of pain on the functional abilities. 38 C.F.R. §§ 4.10, 4.45. Additionally, weakness is as important as limitation of motion, and a part which becomes painful on use must be considered as seriously disabled. 38 C.F.R. § 4.40. Also, where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In a rating decision dated in February 1987, the RO essentially granted service connection for Sjogren's disease, including parotid lymphoma but deferred evaluation of that disability until a VA examination was performed. In July 1987, the RO assigned a 100 percent evaluation for Sjogren's disease, including parotid lymphoma, under Diagnostic Code 6819 of the VA Schedule of Rating Disabilities, effective in September 1986. 38 C.F.R. Part 4. According to the rating decision, Sjogren's disease had its onset prior to service and was aggravated by service and the lymphoma, which appeared during service, was a manifestation of Sjogren's disease. In a July 1989 rating decision, the RO noted that the veteran last had chemotherapy in 1986 and reduced the evaluation for parotid lymphoma, Sjogren's disease, from 100 percent to 10 percent under Diagnostic Codes 7343-7305, effective in November 1989. In October 1990, the RO granted a 30 percent rating for parotid lymphoma, Sjogren's disease, under Diagnostic Codes 6399-6350, effective in November 1989. As noted above, the current appeal originated with a rating decision that granted a 60 percent evaluation for Sjogren's syndrome, effective in March 1996. The 60 percent rating was assigned under the provisions of Diagnostic Codes 6399-6350 of the VA Schedule of Rating Disabilities. 38 C.F.R. Part 4. Prior to August 1996, under Diagnostic Code 6350, constitutional manifestations associated with serous or synovial membrane or visceral involvement or other symptom combinations which were totally incapacitating warranted a 100 percent evaluation. Residuals such as joint, renal, pleural, etc., were rated under the appropriate system, but not combined under Diagnostic Code 6350. The higher evaluation was assigned. 38 C.F.R. Part 4. Under the current provisions of Diagnostic Code 6350, a 60 percent evaluation is warranted for exacerbations occurring two or three times per year and lasting for a week or more at a time; and a 100 percent evaluation is warranted for frequent exacerbations, producing severe impairment of health. Additionally, the disability is evaluated either by combining the evaluations for residuals under the appropriate systems, or by evaluating said disability under Diagnostic Code 6350, whichever results in a higher evaluation. 38 C.F.R. Part 4. The Board notes that, where a law or regulation changes after a claim has been filed or reopened but before the administrative or judicial appeal process has been concluded, the version most favorable to an appellant applies. See Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991). Therefore, the Board will consider both the new and old regulations in evaluating Sjogren's syndrome. Additionally, in Rhodan v. West, 12 Vet. App. 55, (1998), the U.S. Court of Appeals for Veterans Claims (Court) (known as the United States Court of Veterans Appeals prior to March 1, 1999) held that the Board could not apply the revised rating schedule to a claim prior to the effective date of the liberalizing legislation. In determining whether an evaluation of 100 percent evaluation under the current provisions of Diagnostic Code 6350 is warranted, the Board will summarize the pertinent medical evidence. The Board also notes the veteran's contention and testimony that the residuals of his Sjogren's syndrome include dry eyes, dry mouth, joint swelling and pain in his ankles, knees and hips, rectal problems, including hemorrhoids, fatigue, tightening in his hands, and twisting of his index fingers. The Board notes that the veteran is separately service-connected for peripheral neuropathy of the left foot, peripheral neuropathy of the right foot and hemorrhoids, and evaluation of those disabilities is not an issue currently on appeal before the Board. The report of a VA examination for systemic conditions dated in April 1996 shows that there was no renal impairment and no mental changes. With regard to anemia, a complete blood count was within normal limits. The diagnoses included clinical evidence of Sjogren's syndrome. A VA visual examination performed in July 1996 revealed dry eye symptoms which the examiner described as minimal. A VA examination in January 1997 revealed mildly dry eyes and a mild conjunctival infection. According to a VA medical record dated in January 1997, the veteran's eyes were mildly dry with no obvious abrasions of cornea but mild conjunctival injection. At a January 1997 private medical examination, the veteran reported having photophobia secondary to his Sjogren's syndrome and wearing dark glasses frequently. According to the private examination report in November 1997, the veteran had typical findings secondary to his Sjogren's disease; and the examiner indicated that those findings included dry mucous membranes in his eyes. According to a VA medical record dated in May 1997, the veteran's primary symptom of Sjogren's syndrome was dry eye syndrome. The veteran underwent a VA dental examination in October 1996. That examiner diagnosed xerostomia or dry mouth due to decreased salivary gland function which is part of Sjogren's disease. At a VA examination in January 1997, mucous membranes of the mouth were described as very dry. A January 1997 VA medical record also shows that the mucus membranes of the mouth were described as very dry. However, a private medical examination in January 1997 revealed that the veteran had moist oral mucosa. Another January 1997 private medical examination revealed that the oral mucosa was quite dry. However, another private examination in January 1997 revealed moist oral mucosa. According to the November 1997 private examiner, referred to above, the veteran's typical findings secondary to his Sjogren's disease also included dry mucous membranes in his mouth. The January 1997 VA examination, which revealed mildly dry eyes and a mild conjunctival infection, also revealed that the mucous membranes of the nose were dry. The January 1997 VA medical record also shows that the mucous membranes of the nose were dry; and a November 1997 statement from a private physician also indicated that the veteran's typical findings of Sjogren's syndrome included dry mucous membranes in his nose. At the January 1997 VA examination, the parotids were enlarged and firm. One of the January 1997 private medical examinations revealed a swollen right parotid gland. At another January 1997 private medical examination, the right parotid gland was markedly enlarged with measurements of approximately 5 by 7 cm. but nontender, nonmobile and very hard. The left parotid was only slightly prominent. A third January 1997 private examination also revealed that the right parotid gland was swollen. According to a letter dated in January 1997 from William M. Lydiatt, M.D., a private physician, the veteran had a five to six month history of bilateral parotid swelling. Dr. Lydiatt related that the left side went down on its own but that the swelling on the right side had been persistent. Examination revealed bilateral parotid swelling, greater on the right than on the left. A February 1997 private examination report shows that the veteran had right parotid swelling but that it was not increasing in size. According to the private examination report in November 1997, examination revealed right parotid swelling which was hard but nontender to palpation. The April 1996 VA examination for systemic conditions, referred to above, included a musculoskeletal examination which revealed no significant abnormalities. At a July 1996 VA examination of the joints, the veteran complained of continuous joint pain and swelling together with some joint filling. The examining physician diagnosed Sjogren's syndrome having increased rheumatoid manifestations. Examination revealed tenderness of the hands, knees and elbows. With regard to range of motion, both elbows had 135 degrees of motion and the knees had 128 degrees of flexion. There were no problems with the elbows with pronation and supination. With regard to the hands, range of motion of all fingers was 90 degrees or greater. He could easily oppose his thumb and all fingers and he could touch fingertips to the transverse line across the palm of the hand. Also at the VA examination in January 1997, examination of the hands revealed no synovitis and no stiffness. At the latter January 1997 private medical examination, the veteran reported no change in strength and no myalgias or arthralgias on examination of the musculoskeletal system. At the private examination in November 1997, the examined included arthritis primarily affecting his hands in listing the veteran's typical findings secondary to his Sjogren's disease. On examination, the veteran's shoulders, elbows, wrists, hands and knees were without synovitis. Thus, while various symptoms have been medically determined to be residuals of the veteran's Sjogren's syndrome, the preponderance of the probative evidence is against finding that his Sjogren's syndrome is productive of what could reasonably be considered severe impairment of health. As the evidence discussed above shows, the veteran's primary symptom of Sjogren's syndrome is dry eyes. He also experiences dry mouth and dry mucous membranes of the nose and tenderness of various joints. Additionally, while there is probative evidence of swelling of the parotids, they are consistently nontender. The evidence is against finding that such symptoms are productive of severe impairment. The preponderance of the evidence is also against finding that the veteran's Sjogren's syndrome is productive of constitutional manifestations associated with serous or synovial membrane or visceral involvement or other symptom combinations which are totally incapacitating. The Board will also determine whether a rating in excess of 60 percent is warranted by evaluating the various residuals of Sjogren's syndrome under the appropriate systems and combining those ratings. 38 C.F.R. Part 4, Diagnostic Code 6350 (1999). According to Plate II of the VA Schedule for Rating Disabilities, which provides a standardized description of ankylosis and joint movement measurement, the standard range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71. Limitation of flexion of the leg is evaluated under the provisions of Diagnostic Code 5260; and limitation of extension of the leg is evaluated under the provisions of Diagnostic Code 5261. Flexion limited to 60 degrees warrants a noncompensable evaluation; and flexion limited to 45 degrees warrants a 10 percent evaluation. Extension limited to 5 degrees warrants a noncompensable evaluation; and extension limited to 10 degrees warrants a 10 percent evaluation. While the July 1996 VA examination of the joints revealed tenderness of the knees, the knees had 128 degrees of flexion; and there is no probative evidence that the criteria for a compensable evaluation for limitation of motion of either knee are met. Additionally, limitation of flexion of the forearm is evaluated under the provisions of Diagnostic Code 5206. Limitation of extension of the forearm is evaluated under the provisions of Diagnostic Code 5207. According to Plate I, the range of motion of the elbow is from 0 to 145 degrees. 38 C.F.R. § 4.71. Flexion of the either forearm limited to 100 degrees warrants a 10 percent evaluation; and flexion of either forearm limited to 110 degrees warrants a noncompensable evaluation. Extension of the minor forearm limited to 90 or 75 degrees warrants a 20 percent evaluation; and extension of that forearm to 60 or 45 degrees warrants a 10 percent evaluation. Extension of the major forearm limited to 75 degrees warrants a 20 percent evaluation; and extension of that forearm to 60 or 45 degrees warrants a 10 percent evaluation. Under the provisions of Diagnostic Code 5208, when flexion is limited to 100 degrees and extension is limited to 45 degrees, a 20 percent evaluation is warranted for either forearm. 38 C.F.R. Part 4. As discussed above, the July 1996 VA examination of the joints revealed tenderness of the elbows. Additionally, both elbows had 135 degrees of motion; and there is no probative evidence that the criteria for limitation of flexion or the criteria for limitation of extension of either elbow are met. Impairment of supination and pronation is evaluated under the provisions of Diagnostic Code 5213. 38 C.F.R. Part 4. However, the July 1996 VA examination of the joints revealed no problems with the elbows with pronation and supination; nor is there any probative evidence of any limitation of pronation or supination of either elbow. The Board also notes that, when a condition not listed in the VA Schedule of Rating Disabilities is encountered, it is permissible to rate it under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. With regard to the veteran's complaints involving his eyes, competent medical evidence has related his dry eyes to his service-connected Sjogren's syndrome. A VA visual examination in July 1996 revealed that visual acuity was 20/20. A VA examination in May 1997 revealed visual acuity of 20/20 in the right eye and 20/20-1 in the right eye. Additionally, there is no probative evidence that the veteran's dry eyes caused by Sjogren's syndrome is productive of impairment of visual acuity which would met the criteria for a compensable rating. 38 C.F.R. § 4.84a. Aside from possible disfigurement, the preponderance of the evidence is against finding that the veteran's swollen parotids are productive of any ascertainable impairment which would warrant a compensable rating. However, evaluating them as analogous to benign growths of the skins, under Diagnostic Code 7819 and 7800, the Board finds that the enlarged left parotid is productive of no more than slight disfigurement and the enlarged right parotid is productive of no more than moderate disfigurement. There is no probative evidence that they cause marked or unsightly deformity of the eyelids, lips or auricles. 38 C.F.R. Part 4. The Board notes that the RO also considered the provisions of Diagnostic Code 8207 in evaluating the veteran's residuals of Sjogren's syndrome. Under that Diagnostic Code, for impairment of the seventh (facial) cranial nerve, a 10 percent evaluation is warranted for moderate incomplete paralysis; a 20 percent evaluation is warranted for severe incomplete paralysis; and a 30 percent evaluation is warranted for complete paralysis. Additionally, the ratings are dependent upon relative loss of innervation of facial muscles. 38 C.F.R. Part 4. While a July 1996 VA examination revealed diminished prick sensations involving the veteran's face, there is no probative evidence that the veteran's Sjogren's syndrome is productive of what could reasonably be considered more than moderate incomplete paralysis of the seventh cranial nerve. Additionally, paralysis of the ninth (glossopharyngeal) cranial nerve is evaluated under the provisions of Diagnostic Code 8209. Under that Diagnostic Code, a 30 percent rating is warranted for complete paralysis, a 20 percent rating is warranted for severe incomplete paralysis, and a 10 percent rating is warranted for moderate incomplete paralysis. Evaluation depends upon the relative loss of ordinary sensation in the mucous membrane of the pharynx, fauces and tonsils. 38 C.F.R. Part 4. Even assuming the veteran's very dry mouth could be considered productive of severe incomplete paralysis affecting ordinary sensation and his dry nose could be considered productive of moderate incomplete paralysis affecting ordinary sensation, in light of the Board's other findings in this case, the combined rating for the veteran's residuals of Sjogren's syndrome would not exceed the currently assigned 60 percent evaluation under Diagnostic Code 6350. 38 C.F.R. § 4.25. Also with regard to the veteran's complaints of dry mouth, the Board notes that a 10 percent rating is warranted for hoarseness with inflammation of the cords or mucous membrane under the current provisions of Diagnostic Code 6516. The criteria for a 30 percent evaluation under that Diagnostic Code include hoarseness with thickening or nodules of cords, polyps, submucous infiltration or pre-malignant changes on biopsy. Under the provisions of Diagnostic Code 6516 in effect when this appeal began, the criteria for a 30 percent evaluation were severe chronic laryngitis with marked pathological changes such as inflammation of the vocal cords or mucous membranes, thickening or nodules of the vocal cords or submucous infiltration and marked hoarseness. The criteria for a 10 percent evaluation under the previous criteria were status post tonsillectomy is moderate with catarrhal inflammation of cords or mucous membrane and moderate hoarseness. Based on the evidence discussed above, the Board finds that the criteria for 10 percent rating more closely reflect the severity of the veteran's dry mouth symptoms than the criteria for a 30 percent rating under both the new and old diagnostic codes. 38 C.F.R. Part 4. Thus, for the reasons discussed above, the Board finds that the preponderance of the evidence is against the claim for entitlement to an evaluation in excess of 60 percent under Diagnostic Code 6350 or when the residuals of Sjogren's syndrome are rated separately and the ratings combined. 38 C.F.R. § 4.25. Preliminary review of the record does not reveal that the RO expressly considered referral of the case to the Chief Benefits Director or the Director, Compensation and Pension Service for the assignment of an extra-schedular rating under 38 C.F.R. § 3.321(b)(1) (1999). This regulation provides that to accord justice in an exceptional case where the schedular standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extra-schedular evaluation commensurate with the average earning capacity impairment. The governing criteria for such an award is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. The Court has held that the Board is precluded by regulation from assigning an extra-schedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance, however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court has further held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Having reviewed the record with these mandates in mind, the Board finds no basis for further action on this question. VAOPGCPREC. 6-96 (1996). Finally, when after consideration of all evidence and material of record, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving such matter shall be given to the claimant. 38 U.S.C.A. § 5107(b). However, for the reasons discussed above, the Board finds that the preponderance of the evidence is against the veteran's claim for entitlement to an increased rating for Sjogren's syndrome. (CONTINUED ON NEXT PAGE) ORDER Service connection for deep venous insufficiency of the left leg is granted. An increased evaluation for Sjogren's syndrome is denied. JEFF MARTIN Member, Board of Veterans' Appeals