Citation Nr: 1509759 Decision Date: 03/09/15 Archive Date: 03/17/15 DOCKET NO. 11-10 031 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for hearing loss. 2. Entitlement to service connection for tinnitus. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD M. R. Harrigan Smith, Counsel INTRODUCTION The Veteran served on active duty from September 1958 to July 1961. These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee, which denied entitlement to service connection for hearing loss and tinnitus. The Veteran presented testimony before the undersigned Veterans Law Judge at the RO in July 2012; a transcript is part of the record. The Board remanded this case in May 2014 for additional development. FINDINGS OF FACT 1. The Veteran's hearing loss was first shown many years after discharge from service, is not otherwise shown to be related to military service, and has not been caused or aggravated by a service-connected disability. 2. Tinnitus was not manifest in military service, is not attributable to the Veteran's military service, and has not been caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The Veteran does not have hearing loss that is the result of disease or injury incurred in or aggravated by active military service; sensorineural hearing loss may not be presumed to have been incurred in service, and hearing loss was not caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.310, 3.385 (2014). 2. The Veteran does not have tinnitus that is the result of disease or injury incurred in or aggravated by active military service, and tinnitus was not caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2014). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In a pre-adjudication letter dated in February 2010, the RO notified the Veteran of the evidence VA would assist him in obtaining and the evidence it was expected that he would provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). This letter also informed him of the types of evidence that would be considered to substantiate his claims and the information and evidence needed to sustain a claim for service connection. In addition, the letter met the notice requirements set out in Dingess. Neither the Veteran nor his representative has alleged that notice has been less than adequate. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (holding that a party alleging defective notice has the burden of showing how the defective notice was harmful). Further, the Board finds that the letter complies with the requirements of 38 U.S.C.A. § 5103(a), and afforded the Veteran a meaningful opportunity to participate in the development of his claim. Thus, the Board is satisfied that the duty-to-notify requirements under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) were satisfied. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). A remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board remanded this case in May 2014 in order to obtain opinions with regard to whether the Veteran's hearing loss and tinnitus were related to service or were aggravated by medications required to treat his service-connected prostate disability. The opinions were provided in June, October, and December 2014. The Board finds that, collectively, these opinions are adequate because, as shown below, they were based upon consideration of the Veteran's pertinent medical history and medical principles. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). Post-service private medical records and VA examination reports have been associated with the claims file. The Board has reviewed these records to determine whether any other medical evidence relevant to the Veteran's claim exists and has determined that all relevant medical evidence has been associated with the record. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. Background The Veteran contends that he had hearing loss and tinnitus as a result of noise exposure experienced while driving a large truck to pick up and haul large vehicles while on active duty. The Veteran testified that after driving these trucks, he could hear noises that sounded like bees in his ears for hours. Alternatively, the Veteran contends that his hearing loss and tinnitus are due to the prolonged use of antibiotics required to treat his service-connected prostatitis. The Veteran has submitted literature regarding the antibiotics he has taken over the years to treat his prostatitis, which includes indications that some of these medications have been linked to hearing loss and tinnitus. At his hearing, the Veteran contended that he began to notice a hearing loss shortly after service. His wife testified that she noticed his hearing loss since she met him in 1970. Service treatment records do not reflect any complaints or diagnosis of a hearing loss. The Veteran's entrance examination reflected results of whispered voice testing was 15/15. At separation, the Veteran's hearing was as follows: HERTZ 500 1000 2000 3000 4000 RIGHT -10 -5 0 - 5 LEFT -10 -10 0 - 10 The Veteran's separation Report of Medical History reflected his reports that he had no ear, nose, or throat trouble and had never worn a hearing aid. While he had a positive history of runny ears, an examiner noted that this occurred in early childhood, with no residuals. VA medical records included a November 2009 audiology progress note, showing that the Veteran was seen to discuss amplification. The Veteran reported tinnitus heard in both ears. The Veteran was issued and fit with hearing aids. The Veteran was provided with a VA audiological examination in April 2010. He reported that he had in-service exposure to heavy equipment, tanks, tank transporters, and gunfire, and he did not use hearing protection. Following service, the Veteran was exposed to the sounds of construction for approximately three years and factory noises for approximately 32 years. During this time, he was in management and worked primarily in an office setting and wore hearing protection when in the manufacturing areas of the factory. He reported no recreational noise exposure. The Veteran reported that he had tinnitus since the service. The Veteran asserted that he had been on antibiotics since active duty for his service-connected chronic prostatitis. He indicated that he continued to take antibiotics as well as other medications and was concerned that the antibiotics may have affected his hearing/tinnitus. The Veteran reported that he had consulted his physician regarding the effects of long-term antibiotic use but had not had a satisfactory answer as to whether or not his hearing could have been affected. The examiner indicated any opinion with regard to whether hearing loss and tinnitus were related to medications required to treat his service-connected disability should be rendered by a more qualified provider such as an ear, nose, and throat physician. Puretone threshold values were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 30 30 45 45 70 LEFT 30 40 50 65 65 The examiner diagnosed sensorineural hearing loss and tinnitus in both ears, and opined that these were less likely as not caused by or a result of noise exposure while in service. The examiner indicated that the rationale for the opinion was based on the review of the claims file, medical records the Veteran's report, and the results the audiological examination. The examiner noted that service treatment records revealed a whispered voice test at entrance and an audiogram reflecting normal hearing for all frequencies that were tested at separation. The separation audiogram did not include testing at 3000 Hz. However, while the examiner noted that it was possible that that this threshold may have shown some damage due to noise, it was unlikely as all other thresholds were within the normal range. The examiner opined that the Veteran's bilateral symmetrical sensorineural hearing loss, sloping from borderline normal to severe, was consistent with noise exposure as well as other etiologies. The examiner opined that the Veterans tinnitus is most likely related to his hearing loss, and that his hearing loss and tinnitus were less likely as not caused by or a result of in-service noise exposure An additional addendum opinion was provided in December 2010. The examiner noted that the Veteran developed chronic prostatitis while in the service and had continued to have problems with recurrent prostatitis. The Veteran reported that he had required antibiotics approximately twice a year for 30 days since discharge from service. The list of antibiotics included Penicillin and Bicillin, various sulfa drugs, Furadantin, Bactrim, Septra DS, Geocillin, Cipro and Levaquin. These were all taken over the years to treat his chronic prostatitis. The examiner noted that none of these medications was an aminoglycoside, which is the main drug responsible for hearing loss secondary to drug use. He opined that it was certainly less than 50 percent likely that the medications he took were responsible for any hearing loss. A February 2012 private ENT Consult reflected the examiner's opinion that it was possible that the antibiotics taken by the Veteran had caused hearing loss; however, the examiner found that none of the medications he reviewed was classically associated with hearing loss. He noted that, typically antibiotic-associated hearing loss was mostly the higher frequencies and was often associated with vertigo. These were also usually associated with intravenous (IV) administration and in high doses. The examiner noted that the Veteran's noise exposure began in the military, and that he would have liked to review a separation audiogram. He opined that, while the Veteran did have many years of post-military noise exposure, one could easily argue the initiation of his tinnitus and hearing loss during service. A June 2014 VA opinion reflects the examiner's observation that, on entering military service, the Veteran provided no history of hearing loss, and hearing, evaluated only by whisper volume testing, was assessed as normal bilaterally. During his military service, the Veteran was exposed to hazardous noise without hearing protection from loud sounds of heavy equipment, tanks, tank transporters, and gunfire. When he separated from military service the Veteran's hearing was evaluated with audiometric testing and was assessed to have normal hearing bilaterally, and he did not provide a history of ear problems or hearing loss. The examiner noted that because of the inadequate testing of the Veteran's hearing at time of enlistment, it was not possible to evaluate the Veteran's normal hearing upon separation for threshold shifts in hearing at the frequencies tested. The Veteran had been diagnosed with bilateral symmetrical sensorineural hearing loss sloping from borderline normal to severe, with tinnitus as likely as not a symptom associated with the hearing loss. He opined that that the Veteran's hearing loss and tinnitus were less likely than not caused by or a result of in-service noise exposure, taking into account the Veteran's contentions regarding his post-service noise exposure. With regard to the Veteran's contentions that his hearing loss was secondary to antibiotics, the examiner acknowledged that the Veteran was treated systemically with a number of different antibiotics and drugs to treat his genitourinary tract signs and symptoms and laboratory evidence of urethritis, prostatitis and prostatism. He opined that it was less likely than not that any of the medications required to treat his service-connected prostatitis had aggravated his hearing loss or tinnitus. He noted that treatment provided for the Veteran's urethritis and possible Gonorrhea in service, and the medications used to treat the Veteran's service-connected prostate disorder since service. These included Detrol and Ditropan for prostatism, Viagra and Levitra for erectile dysfunction, and several antibiotics, including Floxin, Levaquin, Cipro, Septra DS, Nalfon, Bactrim, Minocin, Restoril, carbenicillin, tetracycline, Gantrisin, Azo-Gantrisin, Lincocin, Furadantin, Gantanol, Azo-Gantanol, Trimpex (trimethoprim), penicillin V potassium, and Chloromycetin for prostatitis. The examiner referenced Flint: Cummings Otolaryngology: Head & Neck Surgery, 5th ed., which provided an overview of antibiotic and other pharmacologic ototoxicity. It was noted that least 96 different pharmacologic agents had potential ototoxic side effects and that aminoglycoside antibiotics were the most common offending agents. This group did not include any of the antibiotics taken by the Veteran. The examiner noted that aminoglycosides were clearly the most problematic, especially when used topically where their use resulted in sensorineural hearing loss and hair-cell damage. He also noted that, for most medications, ototoxicity was dose related and transient. It was his opinion that the antibiotics and other medications the Veteran has taken for prostatitis were not associated with hearing loss. He concluded that the Veteran's degree of hearing loss and tinnitus is consistent with presbycusis--an age related hearing loss. In October 2014, an addendum opinion was provided by an audiologist. The examiner noted that the 2012 private examiner provided an opinion without looking at the Veteran's separation audiogram, which was well within normal limits, or his service record. Therefore, the private examiner was speculating that the Veteran's hearing loss began in service. The VA examiner noted that, in the body of the April 2010 VA examination, the examiner indicated the Veteran's separation audiogram was within normal limits. Therefore, it was the opinion of this examiner that after a review of the Veteran's records, service treatment records and April 2010 examination report, that the Veteran's bilateral hearing loss was less likely than not caused by or is a result of in-service noise events. In December 2014, another addendum opinion was obtained from an audiologist. The examiner concluded that it was less likely as not that the Veteran's claimed hearing loss was incurred in, caused by, and/or aggravated by his time in military service, because of the strong objective evidence of normal separation audiology reports and lack of complaint, diagnosis, treatment and/or events relating to a temporary and/or permanent shift in the auditory thresholds while in military service and over the presumptive period. The examiner noted that a comprehensive medical review of the clinical files, records in VA's online records system, and current medical literature provided the foundation for the opinion. The examiner acknowledged that the Veteran's MOS was as a truck driver, but found that service treatment records were silent for complaints, diagnosis, treatment and/or events related to loss of hearing. Specifically, the objective 1961 separation examination demonstrated normal hearing despite a lack of testing at the 3000 Hz range. Overall, the examiner concluded that it was less likely than not that the Veteran's loss of hearing was related to, caused by and/or aggravated by his time in military service because of the normal range of hearing at separation. The examiner acknowledged the lay statements in the record-including the contention from the Veteran's wife that she noticed that the Veteran had a hearing loss as far back as 1970, and the Veteran's statements clarifying his noise exposure, including noise exposure after service. The examiner noted that these statements were carefully reviewed; however, he found that lay statements are subjective and not viewed with a higher weight than objective medically-based, clinical evidence. Therefore, he concluded that the lack of medically-based, clinical evidence at the time of separation was to be considered but properly balanced against the lay statements and known occupational exposure. The examiner ultimately opined that it was less likely as not that the Veteran's claimed hearing loss was incurred in, caused by and/or aggravated by his time in military service because of the strong objective medically-based, clinical evidence of normal separation audiology reports and lack of complaint, diagnosis, treatment and/or events relating to a temporary and/or permanent shift in the auditory thresholds while in military service and over the presumptive period. These medical conclusions are based on clinical based, VBMS folder, medical evidence from the clinical file, lay statements, and current medical literature. In addition, the examiner opined that the antibiotics and other medications the Veteran had taken for prostatitis were not associated with hearing loss, and that the Veteran's degree of hearing loss and tinnitus was consistent with presbycusis--an age related hearing loss. Analysis Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. A current disability must be present for a valid service connection claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999) (complaints of pain alone do not meet the current disability threshold); Evans v. West, 12 Vet. App. 22, 31-32 (1998). The United States Court of Appeals for Veterans Claims (Court) has held that the current disability requirement is satisfied when a claimant has a disability at the time of filing the claim or during the pendency of that claim, even if the disability has since resolved. McLain v. Nicholson, 21 Vet. App. 319 (2007). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza elements is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496 (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991)). If certain chronic disorders, such as sensorineural hearing loss, become manifest to a degree of 10 percent within one year of separation from active service, then it is presumed to have been incurred during active service, even though there is no evidence of such disability during service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The Court has held that, for chronic diseases listed under 38 C.F.R. § 3.309(a), service connection can be established by showing that the disability has been chronic since active duty. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (noting that the continuity of symptomatology provisions apply only to listed chronic conditions). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection is also provided for a disability, which is proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (2014). The Court has held that service connection can be granted under 38 C.F.R. § 3.310, for a disability that is aggravated by a service-connected disability and that compensation can be paid for any additional impairment resulting from the service-connected disorder. Allen v. Brown, 7 Vet. App. 439 (1995). VA has amended 38 C.F.R. § 3.310 to explicitly incorporate the holding in Allen, except that it will not concede aggravation unless a baseline for the claimed disability can be established prior to any aggravation. 38 C.F.R. § 3.310(b). In relevant part, 38 U.S.C.A. 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ('[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence'). The standard of proof to be applied in decisions on claims for Veterans' benefits is set forth in 38 U.S.C.A. § 5107. A Veteran is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See also 38 C.F.R. § 3.102. When a Veteran seeks benefits and the evidence is in relative equipoise, the Veteran prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). For purposes of applying VA laws, impaired hearing is considered a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, and 4000 hertz (Hz) is 40 decibels (dB) or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, and 4000 Hz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. In Hensley v. Brown, 5 Vet. App. 155 (1993), the United States Court of Appeals for Veterans Claims (Court) held that, even though disabling hearing loss may not have been demonstrated at separation, a Veteran may still establish service connection for a current hearing loss disability by showing he now satisfies the threshold minimum requirements of 38 C.F.R. § 3.385 and by submitting evidence that his current disability is related to his active service. See also Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). The medical evidence described above shows that the Veteran has a hearing loss that meets the criteria for impaired hearing under VA regulations. 38 C.F.R. § 3.385. In addition, the Veteran has a current diagnosis of tinnitus. Brammer, supra. Thus, the issue in this case is whether the evidence of record, including medical and lay evidence, attributes either disability to service or to a service-connected disability. With regard to the Veteran's hearing loss, the Veteran has contended that it began soon after service, but has not made any specific contentions that it began within the first year following his discharge. His wife has asserted that she noted a hearing loss in 1970, approximately nine years after the Veteran's service. In terms of his tinnitus, the Veteran reported experiencing tinnitus in his ears temporarily after noise exposure in service. The Board notes that he is competent to report symptoms as a lay witness. Layno, supra. Hearing loss and tinnitus fall into the category of symptoms that a lay witness is competent to comment on. Therefore, the Veteran and his wife are competent to provide lay evidence with regard to his hearing loss and tinnitus. In terms of evidence providing a link between the Veteran's current hearing loss or tinnitus and his time on active duty, the Board notes that there is no medical evidence which provides such a link. The only medical opinions regarding a nexus to military service are negative opinions provided by VA examiners. The Veteran has not submitted any credible and competent medical evidence of a nexus to service. Rather, the competent medical opinions of record dissociates the Veteran's service from the onset of his hearing loss and tinnitus. With regard to the Veteran's claim that his hearing loss and tinnitus should be service connected on a secondary basis, the Board also finds no basis upon which to award service connection. A review of the record does not reveal any medical opinion in support of these contentions. Particularly, the Board finds the June, October, and December 2014 VA examination reports to be especially probative as the examiners reviewed the record and provided supporting medical rationale for their opinions that the Veteran's hearing loss and tinnitus are not etiologically linked to service or to a service-connected disability. See Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007) (stating that an adequate medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions). The basis for these opinions, in large measure, was that the Veteran had hearing within normal limits at the time of separation from service. Nothing in the record refutes this conclusion or its foundation. This medical examination reports contained clear conclusions with supporting data, and reasoned medical explanations connecting the evidence with the conclusions. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ('[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions'). Absent competent evidence establishing a link between current hearing loss or tinnitus and military service or to a service-connected disability, the Veteran's claims for service connection for hearing loss and tinnitus cannot be granted. The Veteran's statements for treatment purposes do not place the onset of noticeable hearing loss or chronic tinnitus within the first year after service and there is no competent evidence linking the remote onset to an in-service event. Rather, the only competent opinions addressing the origin of either disability are negative. The Board acknowledges the Veteran's assertions that he was exposed to loud noises in service, which he claims caused his hearing loss. In addition, the Veteran has stated his belief that his hearing loss has been caused or aggravated by medications taken to treat his service-connected prostate disability. It is true that the Veteran's lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a) ; 38 C.F.R. §§ 3.303(a), 3.159(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); also see Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). However, to the extent that the lay statements by the Veteran can be accorded any weight in deciding this case, they are not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). The Veteran, as a lay person, without medical training and expertise, is not competent to make an etiological conclusion regarding the cause of his hearing loss or tinnitus. The Board finds that the question regarding the potential relationship between his hearing loss or tinnitus and any instance of his military service, or any other service-connected disability, to be complex in nature. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Relating noise exposure in service to a current disability, including hearing loss and tinnitus, requires opinion evidence from experts with medical training, and is not subject to lay assessment. The Board finds the opinion of the VA examiner to be more persuasive than the Veteran's lay assertions. The medical opinions in this case provide reasons for not believing the lay evidence of continuity since service, especially in light of the evidence showing normal acuity at separation without complaints of hearing loss or tinnitus, which evidence the examiners relied on to conclude that the Veteran did not have current disability associated with military service. In addition, while the Veteran has a current diagnosis of tinnitus, there is no reliable evidence indicating that there is a relationship between the Veteran's current tinnitus and active service. Rather, VA examiners have associated his tinnitus with his hearing loss, as tinnitus is known to be a symptom associated with hearing loss. Accordingly, the Board does not find that the Veteran's hearing loss or tinnitus have been present since active service and further finds that the competent medical evidence weighs against finding a relationship between these current disabilities and the Veteran's period of active service, to include in-service noise exposure. The Veteran has not submitted any evidence to contradict the VA examiner's opinions. As such, the Board finds that the preponderance of the evidence is against the Veteran's claims. Consequently, the benefit-of-the-doubt rule is not helpful to this claimant. See 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55. ORDER Service connection for hearing loss is denied. Service connection for tinnitus is denied. ________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs