Citation Nr: 1309484 Decision Date: 03/20/13 Archive Date: 04/01/13 DOCKET NO. 03-28 261 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Entitlement to service connection for hearing loss. REPRESENTATION Veteran represented by: The American Legion WITNESSES AT HEARING ON APPEAL Veteran and Spouse ATTORNEY FOR THE BOARD A. D. Jackson, Counsel INTRODUCTION The appellant is a veteran who served on active duty from December 1952 to December 1956. The issue initially arose from an August 2001 rating decision by the Chicago, Illinois, Regional Office (RO) of the Department of Veterans Affairs (VA). In April 2005, the Veteran testified at a video conference hearing before the undersigned Veterans Law Judge. A copy of the transcript of that hearing is of record. In a decision dated in November 2010, the Board denied service connection for bilateral hearing loss. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (the Court). In an Order dated on August 4, 2011, the Court vacated the Board's November 2010 decision, and remanded the issue back to the Board for development consistent with the Court's Order. In order to comply with the Joint Motion for Remand (JMR), in November 2011, the Board remanded the claim for service connection for bilateral hearing loss to the RO via the Appeals Management Center (AMC) in Washington, DC. for additional development. The case has been returned to the Board for review. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C.A. § 7107(a)(2). FINDING OF FACT The Veteran's bilateral hearing loss is as likely as not related to his active military service. CONCLUSION OF LAW Resolving all reasonable doubt in his favor, the Veteran's bilateral hearing loss was incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.385 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist 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; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). In this decision, the Board is granting service connection for bilateral hearing loss. This award represents a complete grant of the benefit sought on appeal. Thus, any deficiency in VA's compliance is deemed to be harmless error, and any further discussion of VA's responsibilities is not necessary for this case. II. Analysis Service connection may be granted if it is shown the Veteran develops a disability resulting from an injury sustained or disease contracted in the line of duty, or for aggravation during service of a pre-existing condition beyond its natural progression. 38 U.S.C.A. §§ 1110, 1131, 1153; 38 C.F.R. §§ 3.303, 3.306. 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). Chronic diseases such as organic diseases of the nervous system (which includes sensorineural hearing loss) will be presumed to have been incurred in or aggravated by service, although not otherwise established as such, if manifested to a specified degree (ten percent or more in this cases) within one year after service. This presumption, however, is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1101 , 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. A disorder may also be service connected if the evidence of record reveals the Veteran currently has a disorder specified at 38 C.F.R. § 3.309(a) that was chronic in service or, if not chronic, that was shown in service with continuity of symptomatology demonstrated thereafter. 38 C.F.R. § 3.303(b). These provisions apply to chronic diseases listed at 38 C.F.R. § 3.309(a). Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013). Section 3.303(b) essentially provides two routes by which a veteran can establish service connection for a chronic disease listed at 38 C.F.R. § 3.309(a). For all other diseases that might be considered chronic, medical nexus of a relationship between the condition in service and the current condition is required pursuant to 38 C.F.R. § 3.303(a). Id. The United States Court of Appeals for the Federal Circuit (Federal Circuit) in Walker found that the "[p]rimary difference between a chronic disease that qualifies for § 3.303(b) analysis, and one that must be tested under § 3.303(a), is that the latter must satisfy the "nexus" requirement of the three-element test, whereas the former benefits from presumptive service connection (absent intercurrent cause) or service connection via continuity of symptomatology." Id. First, for the showing of chronic disease in service, (or within a presumptive period per § 3.307), there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." 38 C.F.R. § 3.303(b). Essentially to satisfy the element of a "showing of chronic disease in service", the disease entity must be established and the diagnosis not subject to legitimate question. Subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. Id. When the chronic disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of an evidentiary showing of continuity. Id. Second, where the chronic disease is not shown to be chronic or where the diagnosis of chronicity in service is not adequately supported, then continuity of symptomatology can be established in cases where the claimant cannot fully establish the in-service and/or nexus elements of service connection discussed above. 38 C.F.R. § 3.303(b). The Federal Circuit has held that "[p]roven continuity of symptomatology establishes the link, or nexus, between the current disease and service as the evidentiary tool to confirm the existence of the chronic disease while in service or a presumptive period during which existence in service is presumed." Walker v. Shinseki, supra. The Federal Circuit stated the clear purpose of 38 C.F.R. § 3.303(b) is to relax the requirements of 38 C.F.R. § 3.303(a) for establishing service connection for certain chronic diseases. Id. For continuity of symptomatology, the Board cannot determine that lay evidence lacks credibility solely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). Although symptoms, not treatment, are the essence of any evidence of continuity of symptomatology, the Board may, however, consider a lack of contemporaneous medical evidence as one factor, among others, in determining the credibility of lay evidence. Id. at 1337. See also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed.Cir.2000) (holding that the Board is competent to consider "evidence of a prolonged period without medical complaint, along with other factors" in determining that a condition was not aggravated by service). Disorders diagnosed after discharge may still be service connected if all the evidence, including pertinent service records, establishes the disorder was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). In essence, lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). VA is to give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability benefits. 38 U.S.C.A. § 1154(a). The Federal Circuit held that medical evidence is not always or categorically required in every instance to establish the required nexus or linkage between the claimed disability and the Veteran's military service. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Citing its previous decisions in Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) and Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), the Federal Circuit stated in Davidson that it has previously and explicitly rejected the view that competent medical evidence is always required when the determinative issue in a claim for benefits involves either medical etiology or a medical diagnosis. See id. at 1316. Instead, under 38 U.S.C.A. §§ 1154(a) lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (e.g., a broken leg), (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, 492 F.3d at 1377 (footnote omitted). For example, a layperson would be competent to identify a "simple" condition like a broken leg, but would not be competent to identify a form of cancer. Id. at 1377 n.4. Thus, when considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). In determining whether service connection is warranted, the Board shall consider the benefit-of-the-doubt doctrine. 38 U.S.C.A. 5107(b); 38 C.F.R. § 3.102; Alemany v. Brown, 9 Vet. App. 518 (1996); Gilbert v. Derwinski, 1 Vet. App. 49 (1991). Impaired hearing will be considered a disability for VA purposes when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, and 4000 Hertz (Hz) is 40 decibels or greater; or the auditory thresholds for at least three of these frequencies 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. The Veteran alleges that his present bilateral hearing loss had an onset during military service, specifically due to acoustic trauma and/or ear problems he experienced in service. The Veteran's service treatment records are not available in this case. The RO requested service treatment records from the National Personnel Records Center (NPRC) in July 1999. An October 1999 response shows that the Veteran's service treatment records were likely destroyed in a 1973 fire. Since then there have been request for records through alternate means but have been unsuccessful. Despite the unavailability of the service treatment records, the case law does not lower the legal standard for proving a claim for service connection, but rather increases the Board's obligation to evaluate and discuss in its decision all of the evidence that may be favorable to the claimant. See Russo v. Brown, 9 Vet. App. 46 (1996). Moreover, there is no presumption, either in favor of the claimant or against VA, arising from missing records. See Cromer v. Nicholson, 19 Vet. App. 215, 217-18 (2005) (the Court declined to apply an "adverse presumption" where records have been lost or destroyed while in Government control which would have required VA to disprove a claimant's allegation of injury or disease in service in these particular cases). In various lay statements and during the Veteran's April 2005 video conference hearing, the Veteran reported that he served in the Air Force as a personnel specialist and was assigned to the 802nd Supply Squadron. He worked in the orderly room across the street from the flight line while stationed at Smoky Hill Air Force Base in Kansas. He reported exposure to noise from jet planes on a daily basis. He reported experiencing ear pain as well as hearing problems. He reported to sick call with these complaints and was prescribed analgesics for pain. He reported that he had blockage in the ears lasting approximately three to five minutes. He reported qualifying for weapons while in the Air Force without use of hearing protection. He reported that he frequently went on sick call with reports of ringing in the ears; ear pain, and pain in the teeth. The Veteran's wife, a registered nurse, reported noticing the Veteran's hearing loss since even before they were married in 1976; she was a licensed nurse at the time. A lay statement from the Veteran's sister, dated in January 2002, shows that she noticed a difference in the Veteran's hearing after he returned from service. She stated further that it seemed that the Veteran did not hear as well in one of his ears. The Veteran also reported to her that he had severe colds in service, and that his ears were especially painful at that time. The earliest post-service medical evidence of hearing loss is an August 1999 VA audiological examination. The Veteran reported that he was gradually losing all hearing in his left ear. He reported having several episodes of severe colds and flu with noticeably decreased hearing while in service. He reported that he went on sick call for these episodes and medication was prescribed to clear up his ears. The Veteran reported that some drainage from his ears was possible. The Veteran also reported exposure to hazardous military noise from aircraft which he experienced while stationed near squadrons close to the flight lines. He reported that he qualified on rifle ranges during his basic training. The Veteran was noted to be right handed. He denied any occupational noise exposure. Recreational noise exposure included woodworking with a frequency of approximately once per month. On the authorized audiological evaluation in August 1999, the puretone thresholds in the right ear at 500, 1000, 2000, 3,000, and 4000 Hz were 30, 30, 30, 40, and 60, respectively; and in the left ear they were 75, 80, 70, 60, and 70, respectively. Speech audiometry revealed speech recognition ability of 84 percent in the right ear and of 0 percent in the left ear. An otoscopic inspection of the ears revealed no apparent occlusion, infection, or probable ear canal collapse. The Veteran's was diagnosed with asymmetrical sensorineural hearing loss. He was referred to the Ear Nose and Throat (ENT) clinic. No opinion was provided as to the etiology of the Veteran's hearing loss. A November 1999 VA ENT clinic note shows that the Veteran presented with a history of hearing loss, which had been ongoing since the 1950s. There was no history of ear surgery, head trauma, or ear trauma. The Veteran was noted to be exposed to noise while working in service near a flight line. A physical examination was completed and the Veteran was diagnosed with asymmetrical sensorineural hearing loss, to rule out left retro cochlear pathology. A VA treatment report dated in November 1999 noted that the Veteran reported decreased hearing since 1953. A June 2003 VA examination shows that the Veteran worked in personnel while in service. He stated that in 1953, while stationed in Kansas, his office was located in a building across the street from the flight line. He reported that he went on sick call frequently due to loss of hearing. He stated that it had gotten progressively worse. He also reported that he had frequent colds in service and felt that his hearing got worse with each cold. The Veteran had worn hearing aids since November 2000. The Veteran's medical records were reviewed. On the authorized audiological evaluation in June 2003, the puretone thresholds in the right ear at 500, 1000, 2000, 3,000, and 4000 Hz were 50, 45, 55, 65, and 70, respectively; and in the left ear they were 90, 95, 95, 85, and 90, respectively. Speech audiometry revealed speech recognition ability of 76 percent in the right ear and of 0 percent in the left ear. The Veteran was diagnosed with sensorineural hearing loss. The VA examiner stated, based on the Veteran's report of having been exposed only to military jet noise while stationed in a building across the street from the flight line, he found that it was less likely that the Veteran's hearing loss was related to military noise exposure. This opinion was provided on the basis that service treatment records were not available to ascertain the exact hearing capability of the Veteran while in service. In an October 2009 addendum provided by the June 2003 VA examiner, he stated that the claims file was reviewed. He stated without regard to the Veteran's employment or military history, there is no possible way to provide an opinion in this case relative to the relationship between current hearing loss and previous military noise exposure without resorting to mere speculation. A June 2005 letter from Dr. D.M. shows that the Veteran was seen for a question of hearing loss. His audiogram noted an unequal nerve hearing loss. Nerve hearing loss was usually secondary to acoustic trauma. Dr. D.M. stated, with the Veteran's history of prior intense sound exposure in service, this could be the etiology of the nerve loss. Any intense sound exposure could be the total or partial cause of his hearing loss. A June 2005 clinical note Dr. D.M. shows that the Veteran reported that his hearing loss started around 1952 while he was in service. He reported working around loud noises from jet engines. Per the Veteran's report, he did not complain of hearing loss in service. He started to complain of hearing loss in 1999. An examination was completed and the Veteran was diagnosed with sensorineural hearing loss. On a June 2005 audiological evaluation completed by Dr. D.M., the puretone thresholds in the right ear at 500, 1000, 2000, 3,000, and 4000 Hz were 50, 60, 55, 65, and 75, respectively; and in the left ear they were 95, 100, 90, 85, and 85, respectively. An additional VA examination was completed in March 2010. The Veteran reported that he was exposed to noise from military aircraft on a flight line across the street from his office. Occupational noise included some work on the family farm with tractors and semi-trucks until the fall of 1958 when he worked as an orderly for VA until 1965. The Veteran then worked as an IRS agent. The Veteran also had recreational noise exposure from target shooting prior to and after service. The Veteran was a right hand shooter and used a shotgun. Recreational noise also included motorcycles. On the authorized audiological evaluation in March 2010, the puretone thresholds in the right ear at 500, 1000, 2000, 3,000, and 4000 Hz were 45, 45, 50, 65, and 75, respectively; and in the left ear they were 95+, 105+, 105, 105+, and 105+, respectively. Speech audiometry revealed speech recognition ability of 50 percent in the right ear. Speech audiometry was not provided for the left ear. A physical examination of the ears was completed and the Veteran was diagnosed with asymmetrical sensorineural loss, worse in the left ear with no functional speech recognition in the left ear. The VA audiologist did not provide an opinion at that time because the claims file was not yet available for review. A June 2010 addendum shows that the claims file had been made available and was reviewed thoroughly. The VA examiner noted that she had been informed that the opinion could be made based on lay evidence as well as medical evidence, and that the Board had determined that it was plausible that the Veteran was exposed to noise from the flight line while in service. Although service treatment records were destroyed by fire, the VA examiner noted that the Veteran reported that he complained of pain in his teeth into his jaw radiating up to his left ear, and hearing loss in the left ear when he reported to sick call in service. The Veteran also testified that he experienced blockages of the ears that lasted three to five minutes. The examiner noted further, that even if sick call reports detailing the Veteran's complaints were located, the types of complaints of pain and related hearing loss would not definitively identify current hearing loss as being related to the complaints. Lay statements from the Veteran's sister and his wife were also noted by the VA examiner, as was Dr. D.M.'s June 2005 medical opinion. The VA examiner found, however, that Dr. D.M.'s statement did not identify the Veteran's current asymmetric sensorineural hearing loss as being plausibly related to the type of noise experienced by this Veteran. In that regard, the VA examiner stated that while acoustic trauma may be associated with an asymmetric hearing loss, she indicated that this would be unlikely in the Veteran's situation where there was no consistently increased exposure of the left ear as compared to the right ear while acting as a personnel specialist in the orderly room across the street from the flight line. Based on the configuration of the Veteran's current hearing loss, and the Veteran's report of the type of noise and the environment in which he was exposed to that noise while in the military, the VA examiner opined that it was less likely than not that his hearing loss was directly related to military service. In the August 2011 Joint Motion for Remand (JMR), the parties found, in pertinent part, that the Board erred in its prior decision by not addressing whether the lay statements from the Veteran, his sister, and his spouse were sufficient to establish continuity of hearing loss symptomatology since military service. The Board was also instructed to attempt to obtain certain specified service treatment records. Thus, in November 2011 the Board remanded the claim to obtain the specified records and to obtain a VA medical nexus opinion concerning the etiology of his bilateral hearing loss. The examiner was, in pertinent part, instructed to consider the lay evidence of record which collectively asserts that the Veteran had hearing loss in service and since then. The VA audiologist (who conducted the March 2010 examination) in July 2012 reiterated her conclusion that the asymmetrical pattern of hearing loss shown on audiograms since 1999 is not predicted by the noise exposure of the nature experienced by the Veteran during his military service. As to complaints of ear, jaw and tooth pain in service, the examiner concluded that these symptoms would not likely result in the current type and configuration of the Veteran's current hearing loss. She noted that these symptoms would most often result in a conductive or mixed hearing loss at least initially. While this may account for the Veteran's initial perception of decreased hearing, to have subsequently resulted in the profound sensorineural hearing loss in the left ear would involve chronic middle ear pathology which is not shown by the evidence in this case. In providing the opinion, the VA examiner refers to the statements of the Veteran, his sister, and spouse. She appears to acknowledge the competency of such evidence although she did not specifically address the significance of the lay accounts of in-service symptomatology and continuous post-service symptomatology other than noting that the Veteran's initial perception of decreased hearing may have been due to conductive or mixed hearing loss associated with his complains of ear, jaw and tooth pain. Furthermore, this clinician does not detail or otherwise refer to the Veteran's account of his post-service medical and employment history. Essentially, the examiner does not indicate the significance, if any, of the competent and credible lay evidence of exposure to acoustic trauma as well as complaints of ear related symptoms in service along with the observable loss of hearing by the Veteran and others soon after service and continuing forward. As such, the Board finds that the VA medical opinion is of limited probative weight in that the examiner did not fully assess the value of the lay evidence presented in favor of the claim. The Court held that a medical opinion is inadequate if it does not take into account the Veteran's reports of symptoms and history (even if recorded in the course of the examination). Dalton v. Nicholson, 21 Vet. App. 23 (2007). And, indeed, the Board must make an express credibility finding regarding this lay evidence when eventually deciding these claims. See Id. and Kahana v. Shinseki, 24 Vet. App. at 433 (rejecting broad-sweeping, categorical rejections of lay evidence and testimony without discussing the underlying reasons and bases). The Board must weigh the credibility of these medical opinions to determine their ultimate probative value and, in so doing, the Board may favor one medical opinion over another provided there is sufficient explanation of the underlying reasons and bases. See Evans v. West, 12 Vet. App. 22, 30 (1998). The Board must account for the evidence it finds persuasive or unpersuasive and provide reasons for rejecting material evidence favorable to the claim. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). Indeed in this case, the Board finds that all the medical opinions are somewhat flawed, in that the VA examiner in 2003 could not provide an opinion without additional evidence. The private opinion of Dr. D. M. only indicates that his hearing loss could be related to military service. An examiner saying a condition "could be" related to the Veteran's military service is tantamount to saying it just as well "may not" be related to his service. Medical statements like this, which are inconclusive as to the origin of a disorder, generally cannot be employed as suggestive of a linkage between the disorder and the Veteran's active service. Warren v. Brown, 6 Vet. App. 4, 6 (1993); Sklar v. Brown, 5 Vet. App. 104, 145-6 (1993). However, these types of opinions also cannot be used to rule out this purported correlation, either. See generally Bloom v. West, 12 Vet. App. 185 (1999) (a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty). As noted above, however, the law provides for alternate methods to satisfy the nexus requirements necessary to establish service connection for diseases enumerated at 38 C.F.R. § 3.309(a) such as organic diseases of the nervous system which includes sensorineural hearing loss, and which in this case, as noted by the July 2012 VA examiner has been diagnosed since 1999. In this regard, the Board finds that while the Veteran is competent to report in-service and post-service symptoms of hearing loss as is his sister and spouse, the Board does not find that pursuant to 38 C.F.R. § 3.303(b) the fact of chronicity during service is adequately supported. Layno, 6 Vet. App. at 469. See 38 C.F.R. § 3.159(a)(2). The Board finds that the available evidence is suggestive of a chronic hearing loss condition during service, but not dispositive of a chronic disease. The Board does finds, however, that the Veteran's statements, given the absence of his STRs and the absence of any other significance evidence that diminishes the credibility of such statements, are credible for purposes of establishing that he had symptoms of decreased hearing in service. See 38 C.F.R. § 3.303(b). Further, the Board finds that the Veteran's sister's and spouse's statements are credible as well for establishing continuous hearing loss symptoms since service. The Board cannot determine that lay evidence in the claims folder lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan, 451 F.3d at 1337. The Veteran has reported experiencing bilateral hearing loss continuously since his military service. And there is no inherent reason to doubt either his credibility insofar as purportedly having experienced ongoing difficulty hearing since service or of having experienced the type of noise exposure he claims while in service versus post service. His statements regarding hearing loss and problems with his ears have been consistent since documentation of such problems beginning in 1999. His spouse and sister have also collectively indicated that they noticed his deteriorating hearing soon after service discharge and thereafter. See statement of Veteran's spouse dated in February 2013; spouse's hearing testimony at April 2005 Board hearing; statement of Veteran's sister received in January 2002. As currently codified, VA law defines the "benefit of the doubt" doctrine as: When, after consideration of all evidence and material of record in this case before the Department with respect to benefits under laws administered by the Secretary, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination in the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b). See also 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Here, there is an approximate balance of the positive and negative evidence. Given the current diagnosis sensorineural hearing loss, in addition to the credible history of confirmed in-service acoustic trauma without sufficient evidence of post-service intercurrent acoustic trauma, the credible lay evidence of hearing loss, ear pain and other ear symptomatology in service, the competent and credible lay evidence of continuous hearing loss symptoms since service, and the fact that hearing loss is observable by lay persons, and resolving doubt in the Veteran's favor, the Board concludes the evidence supports service connection for bilateral hearing loss. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Clyburn v. West, 12 Vet. App. 296, 302 (1999) (establishing continuity of symptomatology under § 3.303(b) is an alternative method of satisfying the second and third Shedden/Caluza requirements). Therefore, resolving all reasonable doubt in his favor, it is at least as likely as not that his hearing loss was incurred as a result of service. 38 C.F.R. § 3.102. See also Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (indicating an "absolutely accurate" determination of etiology is not a condition precedent to granting service connection, nor is "definite" or "obvious" etiology). ORDER Service connection for bilateral hearing loss is granted. ____________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs