1. I am sharing a nexus letter I submitted. I had to convert to Word to share. I removed names and dates.
   
2. I also submitted VA sleep study
3. CPAP Usage report ( Not noted in denial )
4. Copies of studies noted in Nexus
5. Private sleep doctor records
6. VA medical records to include diagnosis for Tinnitus and attempt to claim Sleep Apnea as Secondary

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📷📷📷📷I consulted w ith Removed Name ans on August .At that tim e, I review ed his m edicalhistory and pertinent VA m edicalrecords.As you are aw are,Removed Name is an Arm y Veteran of the G ulf W ar Era w ith active-service dates from February to February .

📷📷📷Removed Name tells m e, , M D , FAASM ,that he had sym ptom s suggestive of O bstructive Sleep Apnea during his active service including but not lim ited to snoring.

📷The veteran also m entioned to m e that his disturbed sleep began during his year long training period. D uring this tim e Removed name had an irregular schedule that required him to attend training at night for eight hours or during the day for eight hours.

📷As you are aw are, Removed Name has established service connection for tinnitus w ith a disability rating of 10% .

📷Removed Name also has service connections for otherspecified depressive disorder w ith anxious distress and m igraine headaches, w hich com m on research has found to be causative factors in obstructive sleep apnea.As w ellas service connections for right knee strain w ith degenerative arthritis; sprain, rightfoot; and sprain, left foot, w hich have been found to be aggravating factors due to chronic pain.

📷In review ing the veteran’s m edicalrecords, it is im portant to note that Removed name is clinically diagnosed as obese, and this has also been show n to be a causative factor of obstructive sleep apnea in distinguished m edicalresearch.

📷removed name com pleted a sleep study through the Atlanta VA Sleep M edicine C enter on April16, 2019 and w as diagnosed w ith obstructive sleep apnea. The veteran w as placed on PAP therapy at that tim e, and it is required that the veteran continues thattherapy to the present day.

O bstructive sleep apnea occurs w hen the m uscles thatsupport the soft tissues in your throat, such as your tongue and soft palate, tem porarily relax. W hen these m uscles relax, your airw ay is narrow ed or closed, and breathing is m om entarily cut off.

Signs and sym ptom s of obstructive sleep apnea include:

● Excessive daytim e sleepiness

● Loud snoring

● O bserved episodes of stopped breathing during sleep

● Abrupt aw akenings accom panied by gasping or choking

● Aw akening w ith a dry m outh or sore throat

● M orning headache

● D ifficulty concentrating during the day

● Experiencing m ood changes, such as depression orirritability

● H igh blood pressure

● N ighttim e sw eating

● D ecreased libido

📷W ith respect to service-connected tinnitus.The veteran developed tinnitus during his service as a result of operating large generators and electricalequipm ent.

Tinnitus is described as a ringing or Name removed noise in one or both ears that m ay be constant or com e and go, often associated w ith hearing loss.

N ew research suggests sleep apnea m ay also be associated w ith hearing loss and tinnitus. Tinnitus can also m ake it difficult to get a good night's sleep,w hich can com pound the sleep problem s associated w ith sleep apnea.

A study found in A nnals of O tology, R hinology & Laryngology com pared sleep architecture in patients w ith and w ithout chronic tinnitus. The results show ed thatpatients w ith tinnitus have significant alterations in

R EM sleep latency as w ellas the R EM sleep phase.

R esearchers estim ate that tinnitus im pacts the quality of sleep for 50-60% of people w ith sleep disorders.

In another study, Lainoted that C PAP helps som e tinnitus patients by providing better sleep quality and higher oxygenation during sleep.

H e concluded that tinnitus and sleep disordered breathing m ay be tw o sides of the sam e coin; tinnitus causes O SA and O SA aggravates tinnitus. That is, they are either co-m orbidities or etiologically related.

C om m only used to treat sleep apnea, C PAP therapy can also m inim ize tinnitus because of your body's im proved blood oxygen levels.As these levels im prove,there is a reduction of pressure on your ears, w hich sim ultaneously alleviates tinnitus sym ptom s.

📷W ith respect to Name removed ’clinicaldiagnosis ofobesity. The veteran is 69 inches in height and roughly 253 lbs w ith a BM I of 37.4.A BM I of 30 and above is clinically diagnosed as obese.

The veteran stated that his difficulty w ith w eightbegan w hen he w as required to w ork an irregular schedule during training causing him to develop irregulareating habits.

📷Name Removed also has service connection for otherspecified depressive disorder w ith anxious distress. People w ith depression or anxiety m ay experience w eightgain or w eight loss due to their condition or the m edications that treat them . D epression and anxiety can both be associated w ith overeating, poor food choices, and a m ore sedentary lifestyle. O ver tim e,w eight gain m ay eventually lead to obesity.

Poor sleep and persistent stress m ay cause you to gain w eight. N ot getting enough sleep can affect horm ones that regulate your appetite, m aking you eatm ore food than you need. Som e people cope w ith stress by eating junk food regularly. In response to stress, your body releases a horm one that prom otes visceralfat.

Leptin, the horm one that tells you to stop eating,is produced less often w hen you are sleep deprived.

M ore ghrelin plus less leptin equals w eight gain.The veteran is eating m ore and the m etabolism is slow er w hen you are sleep-deprived.

📷In addition, Name removed service connections for right knee strain w ith degenerative arthritis; sprain, right foot; and sprain, left foot can prevent m eaningfulexercise due to chronic pain.

Individuals w ith chronic pain often experience less deep sleep, m ore aw akenings during the night, as w ell as less efficient sleep. Thus, the quality of sleep is often light and unrefreshing. This non-restorative sleep pattern can then cause dim inished energy, depressed m ood, fatigue, and w orse pain during the day.

Sleep apnea is a sleep disorder resulting in interrupted sleep caused by breathing problem s. W hen you are diagnosed w ith sleep apnea, your upper airw ay is blocked w hen you are asleep.

If left untreated, the effects of sleep apnea can get w orse. Sleep is an im portant part of the body's recovery process; frequent interrupted sleep can raise stress levels, resulting in high blood pressure and an increased risk of heart disease. Sleep apnea has also been linked to stroke and Type 2 diabetes.

C ontinuous positive airw ay pressure therapy (C PAP)uses a m achine to help a person w ho has obstructive sleep apnea (O SA) breathe m ore easily during sleep.A C PAP m achine increases air pressure in your throat so that the airw ay doesn't collapse w hen you breathe in.

📷📷W hile sym ptom atically, name removed O SA is greatly alleviated w ith the use of C PAP therapy, unfortunately, it does not am eliorate the underlying causative agent of his above m entioned com orbidities and those disease(s) sym ptom atology, as they continue to adhere to the veteran’s restorative sleep, and overallquality of life, w hile stillexperiencing excessive day-tim e hypersom nolence.

After review ing the veteran's m edicaland m ilitary records, it is m y expert m edicalopinion that itis m ore likely than not, a 50% chance or greater, that the veteran's diagnosed obstructive sleep apnea is caused or aggravated by his established service-connection of tinnitus.

R espectfully subm itted,

📷📷

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Referencing the following research and liteforatheureabove claims, as well as citationsVAfromwherethe a veteran was successful in connecting the above-mentioneddiseases:

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● https://journals.sagepub.com/doi/abs/10177/0003489418805766.

● https://lowtcenter.com/news-article/sleep-apnea-tinnitus-hearing-loss/

● https://onlinelibrary.wiley.com/doi/10.111/coa.13024

● https://www.healthline.com/health/migraine/migraine-ringing-in-ears#1

● https://americanmigrainefoundation.org/resource-library/understanding-migrainetinnitus-and-headache/

● https://www.va.gov/vetapp10/files6/1046761.txt

● https://www.healthline.com/health/depression/obesity-and-depression

● https://www.va.gov/vetapp09/files2/0911508.txt

● https://www.spine-health.com/wellness/sleep/chronic-pain-and-insomnia-breaking-cycle

● https://obesitymedicine.org/sleep-apnea-and-obesity/

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● https://www.mayoclinic.org/healthy-lifestyle/adult-health/expert-answers/sleep-and-weight-gain/faq-2005819 8

● https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3173758/

● https://www.va.gov/vetapp16/files3/1624350.txt

● https://www.pulmonologyadvisor.com/home/topics/obstructive-sleep-apnea-osa/obstructive-sleep-apnea-con fers-higher-risk-for-mental-and-cognitive-impairment/

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