Citation Nr: 1322270 Decision Date: 07/11/13 Archive Date: 07/18/13 DOCKET NO. 05-12 255 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUE Entitlement to service connection for a disability manifested by chronic vertigo. REPRESENTATION Appellant represented by: Scott E. Schermerhorn, Attorney at Law WITNESSES AT HEARING ON APPEAL Appellant & Spouse ATTORNEY FOR THE BOARD A. Barone, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from September 1960 to September 1963. The case is before the Board of Veterans' Appeals (Board) on remand from the United States Court of Appeals for Veterans Claims (Court). The case was originally before the Board on appeal from a September 2003 rating decision of the Philadelphia, Pennsylvania Department of Veterans Affairs (VA) Regional Office (RO) that declined to reopen the Veteran's claim of service connection for chronic vertigo. In January 2009, a Travel Board hearing was held before the undersigned. A transcript of the hearing is associated with the Veteran's claims file. In a decision issued in September 2009, the Board reopened and denied on de novo review the Veteran's claim of service connection for chronic vertigo. He appealed that decision to the Court. In September 2011, the Court issued a memorandum decision that vacated the September 2009 Board decision and remanded the matter on appeal for readjudication consistent with the instructions outlined in the memorandum decision. In May 2012, the Board remanded this appeal to the RO for necessary additional development. The Board has carefully reviewed the September 2011 Court memorandum decision and notes that it refers only to the September 2009 Board decision's denial of service connection for a disability manifested by chronic vertigo; it does not refer to the aspect of the September 2009 Board decision that granted the Veteran's petition to reopen that claim for de novo review. The September 2011 Court memorandum decision directives appear to assume that the claim has been reopened. The Board finds that the portion of the September 2009 Board decision that granted the petition to reopen the claim has not been disturbed by the September 2011 Court memorandum decision; such determination does not prejudice the Veteran (the reopening of the claim was a grant of his petition). The Board will proceed to a merits review of the Veteran's service connection claim, in accordance with the Court's directives. The appellant is not prejudiced by the Board's proceeding with de novo review of this claim without returning it to the RO for their initial de novo consideration because the RO had already itself reopened the claim and adjudicated the matter de novo before certifying the appeal for Board review. The Board notes that a July 2012 VA examination report, developed during the processing of the Board's May 2012 remand, clarifies that the Veteran's "vertigo" is a symptom and not a diagnosis in its own right. The Board has accordingly recharacterized the issue on appeal as "entitlement to service connection for a disability manifested by chronic vertigo." FINDING OF FACT A disability manifested by chronic vertigo is not shown to be related to the Veteran's service, to include the August 1962 hospitalization therein. CONCLUSION OF LAW Service connection for a disability manifested by chronic vertigo is not warranted. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The VCAA applies to the instant claim. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any 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 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: 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, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran was advised of VA's duties to notify and assist in the development of his claim prior to its initial September 2003 adjudication. An August 2003 letter explained the evidence necessary to substantiate his claim, the evidence VA was responsible for providing, and the evidence he was responsible for providing. He has had ample opportunity to respond/supplement the record, and is not prejudiced by any technical notice deficiency (including in timing) that may have occurred earlier in the process. In compliance with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), a May 2008 letter informed the Veteran of disability rating and effective date criteria. While fully adequate Dingess/Hartman notice was arguably not provided prior to the initial adjudication of the instant claim, the case was subsequently readjudicated in a March 2013 supplemental statement of the case (SSOC), curing any notice timing defects. Prickett v. Nicholson, 20 Vet. App. 370 (2006). The Veteran has not alleged that notice in this case was less than adequate. The Veteran's service treatment records (STRs) were previously associated with his claims file, and pertinent treatment records (and records from Social Security Administration (SSA)) have been secured. The RO arranged for a VA examination in July 2007 and another one (in accordance with the Board's remand directives) in July 2012. As discussed below, the Board finds that the report of the July 2012 VA examination is adequate for the purpose of this decision. A Board hearing before the undersigned was held in January 2009. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge (VLJ) who conducts a hearing must (1) explain the issues and (2) suggest the submission of evidence that may have been overlooked. At that January 2009 hearing, the service connection issue currently on appeal was still subject to a petition to reopen with new and material evidence. However, the VLJ explained that the claim had been reopened at the RO level and the VLJ identified specifically which elements of service connection had been established in the prior adjudication; the VLJ also repeatedly directed attention to the need to submit evidence that shows a medical nexus between the current vertigo symptoms and the Veteran's in-service flight experiences and/or his in-service symptomatology. The Veteran was assisted at the hearing by his representative, and the hearing presentation demonstrated actual knowledge of the elements required for service connection through testimony concerning in-service events, current disability, and the allegation of a causal link between the current disability and service. Accordingly, the Veteran is not shown to be prejudiced on this basis. Finally, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claim(s), and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. As such, the Board finds that no further action pursuant to Bryant is necessary. The Board finds there has been compliance with the instructions of the Board's May 2012 remand addressing the issues raised by the Court's September 2011 memorandum decision. A new July 2012 VA examination report contains medical opinions addressing each question presented by the Board's remand directives. The Veteran has not identified any pertinent evidence that remains outstanding. VA's duty to assist is met. Accordingly, the Board will address the merits of the claim. Factual Background The Board notes that it has reviewed all of the evidence in the Veteran's claims file, and in Virtual VA (VA's electronic data storage system) with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. The Veteran seeks service connection for chronic vertigo, and claims that his current and chronic vertigo (which was first clinically documented in 1999) is related to the vertigo he experienced in service when he had to fly to Korea. He has related that the trip involved several layover flights: from Pennsylvania to California, followed by Alaska, Japan and then Korea, and that he experienced problems on each leg of the trip, with symptoms worsening with each flight. He claims that by Japan, he was dizzy, unable to stand or talk correctly, and had to be hospitalized. He also claims that he has had motion sickness, vertigo, and dizziness ever since service such that he has never flown or been on a boat postservice. Service treatment records (STRs) show that in August 1962, the Veteran was hospitalized in Japan for 3 days after complaints of bilateral shoulder pain and an elevated temperature for two days. On physical examination, his ears were clear, his throat slightly red, and his submandibular nodes were palpable. A chest examination was normal. Flu-like syndrome was diagnosed. The Veteran's STRs also show that in his May 1960 service enlistment report of medical history, he indicated that he did not have a past or current problem with car, train, sea or air sickness. However, in his July 1963 service separation report of medical history, he indicated having a past or current problem with car, train, sea, or air sickness. His service separation physical examination report is silent for any complaints, findings, treatment, or diagnosis of dizziness and/or vertigo. To support his claim that he experienced vertigo in service, the Veteran submitted a copy of a postcard he sent to his parents from Alaska while en route to Korea in 1962. He wrote, "I left quicker than I thought from Oakland, hope you got my letter, I think I got enough airplane rides for this year, but I'll be glad to take as many as they give me next to get home.... I'll write soon in Japan but my ears still hurt from flying." VA treatment records show that in June 1999, the Veteran was hospitalized following complaints of dizziness and double vision for one week. It was noted that he had experienced five prior episodes of vertigo. Neurological examination found that he could not abduct the right eye completely, had double vision on extreme right lateral gaze, and had horizontal nystagmus. There was no facial weakness and cranial nerves III and VI were intact. Gag reflex was present and motor strength and sensation were intact. Coordination and cerebellar function revealed he was clumsy on the right side, and had poor alternating movements of his right hand. An MRI was reviewed with a neurologist who noted that it was not of good quality, but showed some small punctate lesion on the right posterior frontal area in the sulci. On discharge, the diagnoses were: 1) right cerebellar syndrome, metastasis or bleeding ruled out; and 2) possible right small pontine lacunar stroke. A few days later, also in June 1999, the Veteran was admitted to the VA hospital after his family observed irrational behavior at home. Neurological examination was essentially unremarkable; a lumbar puncture was negative except for slightly elevated protein; and an MRI did not reveal any underlying pathology. The diagnoses were adjustment disorder and status post right cerebellar syndrome, etiology not clear. In September 1999, the Veteran was evaluated by an otorhinolaryngologist, Dr. M.A.O., whose impression was that the Veteran had disequilibrium and dizziness - rule out vestibulopathy. Dr. M.A.O. found that both tympanic membranes were clear and intact. He recommended that the Veteran undergo an ENG. A November 2001 ENG showed left vestibular paresis. A September 1999 private treatment record from Dr. R.M.S. at the John Heinz Institute of Rehabilitation Medicine shows that the Veteran had reported having episodes of vertigo since May 1999. He reported that several weeks before he began having the episodes he bumped his head and had a low-grade fever without other signs of infection. He complained of difficulty thinking and his wife complained of personality changes. He reported that he had had four episodes of vertigo over the years, each about a day or two long, and that the first episode occurred in service. A neurological examination was normal; the impression was recent attack of prolonged vertigo, ataxia, and double vision, rule out demyelinating disease, and rule out toxic-metabolic, inflammatory process, and infectious process. In May 2000 the Social Security Administration (SSA) awarded the Veteran SSA disability benefits due to a neurological primary disability and a musculoskeletal secondary disability, effective November 1999. A June 2000 VA outpatient treatment record shows that the Veteran complained of problems that began in May 1999 with an acute onset of dizziness accompanied by severe vomiting and double vision. He denied tinnitus, hearing loss, fullness or pressure in the ears, or fluctuating hearing prior to the "attack." He also reported that his vertigo and vomiting had subsided, but that he still had constant dizziness. Examination revealed that he was alert and oriented, but very anxious. His tandem gait was unstable, but his cranial nerves were intact. His ear canals were clear, tympanic membranes were normal, and there was no evidence of otitis media, middle ear effusion, or otitis externa present. There was a small exostosis of the right external ear canal. The examining provider's impression was that the Veteran had an acute vestibular episode in May 1999 of unclear etiology. He also noted that the Veteran's central nervous system and other complaints could not be explained and that his emotional problems were a contributing factor. A September 2000 letter from Dr. V.B.N. stating that he had reviewed the Veteran's records and obtained his medical history, including all of his radiology reports, which were negative, except for decreased vertebral response of the left side on ENG. The Veteran was anxious on examination. Neurological examination showed that cranial nerves were intact, but there was some nystagmus or extreme right lateral gaze. There was no facial paralysis, motor weakness, or loss of sensation, and reflexes were 2+. Dr. V.B.N. opined that although the Veteran's MRI of the brain was negative, a possible small brain stem stroke affecting the vestibular nuclei could not be ruled out, and was "more likely ... the reason for his symptomatology." A December 2000 VA neurology consultation report with Dr. I.K. shows that the Veteran complained of dizziness, described as "lightheadedness and [a] floating sensation in the head." Dr. I.K. noted that the Veteran was taking medication for mild depression and that an MRI of the brain reportedly showed fullness of the ventricles and mild atrophy. He noted that these findings were not age-appropriate. Motor strength, reflexes, and sensation were normal. A mental status examination was normal except for occasional errors in word output. A cranial nerve examination showed nerve deafness on the right side and mild nystagmus on the right, without reproduction of the vertigo. Dr. I.K.'s assessment was, "I feel [the Veteran's] vertigo is secondary to Ménière's disease. Other possibilities include benign positional vertigo." In June 2002, Dr. M.A.O. referred the Veteran to Dr. Y.R. at Johns Hopkins Medicine. The Veteran's chief complaint was disequilibrium. After reviewing the Veteran's history and performing a physical examination, it was his impression that the Veteran had left-sided vestibular hypofunction, which was likely the result of a mini stroke he sustained 4 years prior. He then reviewed the 1999 MRI by Dr. Z. and found no obvious stroke on the film, but noted that Dr. Z had recommended that a repeat MRI be done using a stroke protocol to further evaluate the Veteran's symptoms. Dr. Y.R. found no evidence of benign paroxysmal positional vertigo, Ménière's disease, or any other medically-treatable etiologies. In March 2003, the Veteran's VA neurologist, Dr. I.K., stated that he had reviewed the Veteran's service enlistment and separation reports of medical history and noted that upon entry, the Veteran had denied any symptoms of dizziness at entry. However, upon separation, he stated he had problems with flying and did not like to fly. Based upon his review, Dr. I.K. stated, "This may indicate that he might have had some sort of change in health condition during [service] which caused him to not like flying (? caused vertigo). He states he flew in cargo planes with inadequate pressures in the cabin. Could that have caused barotrauma? I am speculating as I can't be sure here." On March 2003 evaluation by Dr. B.J.K., the Veteran reported having a serious bout of vertigo in 1999 and experiencing problems with vertigo and dizziness ever since. He stated that he had had problems with vertigo ever since he had to fly in service, and reported he was hospitalized for vertigo and nausea in service. Based on the Veteran's history, Dr. B.J.K. opined that the Veteran had "some chronic vertigo that may have been caused, or was probably exacerbated by the flight in service"; the rationale included that he had been hospitalized at that time. In November 2003, the Veteran was evaluated for his balance difficulties by Dr. D.S. at the Hospital of the University of Pennsylvania. He reported that his spells of dizziness began approximately 5 years prior and were similar to spells he had experienced in service. These spells were characterized by neck pain, nausea, vomiting and imbalance. He was unaware of any auditory or aural symptoms which accompanied these spells, but noted that he was frequently on aircraft and was concerned they were responsible for his current dizzy spells. It was also noted that about one week prior to his dizzy spell 5 years earlier, the Veteran has suffered some minor head trauma at work. Dr. D.S. reviewed the Veteran's record and found that an MRI scan was negative for any abnormality, electronystagmography performed 3 years in a row from 1999 to 2001 showed significant loss of labyrinthine function on the left, and that an October 2003 balance function test showed complete loss of caloric response in the left ear. Dr. D.S. found that the Veteran had noncompensated left unilateral peripheral vestibular loss. In his opinion, it was most likely that the Veteran suffered his unilateral vestibular loss at the beginning of his severe episode of vertigo 5 years prior, as his testing had indicated a loss of both semicircular canal and otolith (saccular) function, and this could have accounted for his vertical double vision, nausea, vomiting, ataxia and vertigo. Dr. D.S. doubted whether the Veteran's minor head strike or anything that might have happened 40 years ago in service would have contributed to this vestibular loss, but stated that it was possible that he suffered a partial loss on the left side while in service, which was compensated and that he had a further loss of function more recently. Dr. D.S. also stated that an alternative explanation for the Veteran's complaints could be that he had a migraine, as he had a family history of headache and the quality of his headaches were consistent with migraine. Dr. D.S. then stated that he would not be comfortable attributing the amount of unilateral vestibular loss and hearing loss only to migraine, but noted that previous episodes of head or neck pain, nausea and vertigo could certainly be the result of a migraine. On July 2007 VA examination, the examiner found no correlation between the Veteran's complaints of vertigo and his military service, as his vertiginous episodes began in June 1999, long after his military discharge. The examiner explained that there were no references in the Veteran's STRs of him having a motion-like sickness or aversion while in moving objects in the military. In April 2009, the Board reviewed the entire claims file and found that because the above-described medical opinions did not point to the same facts in the record, the etiology of the Veteran's chronic vertigo remained unclear. Therefore, it sought a medical advisory opinion from the Veterans Health Administration (VHA). In April 2009, the VHA consultant (a VA otolaryngologist) reviewed the record and opined that it was unlikely that the Veteran's 1962 hospitalization in service was related to the postservice diagnoses rendered and treated. He explained that although the Veteran's STRs showed he was treated for a flu-like illness in August 1962, the records were silent for any otologic symptoms and the ears were documented as normal. The only reported supporting documentation of ear problems in service was from the appellant's postcard which stated, "I'll write soon in Japan but my ears still hurt from flying." The VHA consultant noted that ear fullness, pressure, and pain frequently occur with altitude changes, and observed that the Veteran's STRs were silent for otitis media, hearing loss, nystagmus, or vertigo. These are symptoms commonly associated with injuries resulting from barometric pressure changes. The VHA consultant also noted that the Veteran was hospitalized twice in June 1999 with the following diagnoses: right cerebellar syndrome, metastasis or bleeding ruled out, possible right small pontine lacunar stroke, and adjustment disorder not otherwise specified. He was reported to have dizziness and double vision. Vertigo, the VHA consultant explained, could be of central (brain, brain stem), peripheral (inner ear), or combined (central and peripheral) origins. Given the nature of the Veteran's June 1999 diagnoses, the VHA consultant opined that the Veteran's dizziness in June 1999 was likely of central origin and not peripheral. He noted that the Veteran was also given diagnoses of left vestibular weakness (in November 2001), left vestibular hypofunction (in 2002), and left peripheral vestibular loss and migraine (in November 2003). He explained that vestibular paresis is characterized by imbalance and vertigo, thus supporting a diagnosis of vertigo with a possible peripheral (as opposed to central) etiology; however, in his opinion, it was not related to the Veteran's service as there was no supporting documentation of imbalance and vertigo in the STRs. As the left vestibular hypofunction was felt to be related to a mini-stroke, the VHA consultant opined that it was of central origin. The VHA consultant also noted that a June 2000 audiological evaluation revealed that the Veteran had mild to moderate symmetric sensorineural hearing loss with speech recognition ability of 100 percent in the right ear and 96 percent in the left ear. These results, he explained, were typical for those who are over age 60. He observed that there was a lack of significant low frequency loss, which is typically associated with Ménière's disease (vertigo, hearing loss, tinnitus, and aural fullness). Asymmetric hearing loss, which is usually seen in individuals who have perilymph fistula from barometric changes (such as air travel), was also not shown. Based on the foregoing, the VHA consultant concluded that the diagnoses rendered beginning in 1999 were unlikely related to the Veteran's military service (from 1960 to 1963). In a July 2009 memorandum, the Veteran's representative argues that the April 2009 VHA advisory opinion is inadequate as it is conclusory without providing sufficient explanation for his rationale. He also argues that the VHA consultant did not address whether the Veteran suffered from barotrauma in service and whether the Veteran's complaints of motion sickness in service represented a continuation of his symptoms from service to the present. In support of his argument, he included a medical article by Dr. C.G.M., titled, "Perilymphatic Fistula." The Veteran has submitted another medical opinion in support of his claim. In this undated medical opinion, received in March 2012, J.J.O., D.O., states that the Veteran has been under his primary medical care since March 2001, and that he has also treated him for chronic vertigo. The Veteran reports that these symptoms date back to and stem from an airplane flight in service. Observing that vertigo and tinnitus can develop from "several inciting factors or as part of a variety of medical conditions," J.J.O., D.O. states that "it is certainly plausible that [the Veteran] developed this affliction during his service related time and more specifically incurred the disorder itself during this air flight in 1962, with barotrauma as the casual mechanism of injury." He also adds that he has "no other obvious etiology to hang [his] hat on and [that] he [has] no reason not to believe that what [the Veteran] has stated is actual and true." The Board's vacated September 2009 decision relied, essentially, on the April 2009 VHA medical advisory opinion to deny the Veteran's claim, and the Veteran appealed that decision to the Court. In September 2011, the Court issued a memorandum decision which found the April 2009 VHA medical advisory opinion to be inadequate because the VHA consultant failed to discuss significant facts from the Veteran's STRs. In light of the Court's instructions, the Board directed that the Veteran be provided another VA examination for a medical opinion. The Veteran underwent a new VA examination in July 2012. The July 2012 VA examination report presents detailed discussion of pertinent medical history as well as current medical findings and diagnoses informed by interview and examination of the Veteran together with review of the claims-file. An addendum to this report (also dated in July 2012) presents the specific medical opinions requested by the Board's May 2012 remand. The July 2012 VA examiner explains that the Veteran's vertigo "is a symptom, not a disease entity." The examiner concludes that the Veteran's "vertigo since 1999 is due to the unilateral vestibular loss, the etiology of which is unknown." In this regard, the VA examiner cites the "extensive testing" of neurological function by Dr. D.S. at the Hospital of the University of Pennsylvania resulting in diagnosis of "unilateral vestibular loss which became prominent in 1999." The VA examiner commented that the "testing indicates a loss of both semicircular canal and otolith function which would account for all of his symptoms." The examiner notes that the Veteran's "minor TBI" was considered "not related to his symptoms." The VA examiner then also notes that the Veteran had "an MRI of the brain and internal auditory canals which was normal" and "[n]eurologic evaluation was negative." The examiner comments that "[i]t could possibly be on a vascular basis or a neuropathy or perhaps metabolic or infectious." In essence, however, the July 2012 VA examiner's discussion in this regard concludes that the Veteran's vertigo is not a disease entity, but is a symptom due to unilateral vestibular loss of unknown etiology. The July 2012 VA examination report then turns to addressing the question of whether the current chronic vertigo is etiologically related to the Veteran's August 1962 hospitalization and/or his service rather than any event or illness of post-service onset. The examiner agreed with Dr. D.S. in acknowledging that "it is certainly possible that he suffered a partial loss on the left side while in the service which was compensated and that he had a further loss of function in 1999." However, while acknowledging that possibility, the VA examiner found that this scenario was unlikely. The VA examiner cited that "[t]here are no indications of any central nervous system lesion" and that there is "normal examination and MRI scanning" such that the examiner concludes: "Therefore, as far as probability to service connection, I think that the claimed condition was less likely than not incurred in or caused by the claimed in-service event." With consideration of the available information, the examiner discussed his rationale that "[i]t is highly unlikely that the event in 1962 would smolder for thirty seven years and then cause a catastrophic event in 1999, resulting in complete disability." The examiner further explains that "vertigo is multifactorial and the event in 1962 could have been caused by many other diseases completely unrelated to the 1999 event." Finally, the July 2012 VA examination report turns to the question of whether the record reasonably supports a finding that the Veteran suffered from barotrauma in service that may be related to his current vertigo. The examiner concluded: "I do not think that the record reasonably supports the veteran suffering from barotrauma in service." In explaining this conclusion, the examiner particularly discussed "the patient's health record dated 26th August 1962 at Kishine Dispensary," and considered that the report "states that the patient complained of pain in both shoulders for two days, temperature 101. Ears were clear. Throat slight redness, some mandibular nodes. Chest x-ray. Rx, admit. Diagnosis, flu-like syndrome." Significantly, the examiner explains that "[i]f barotrauma was significant enough to cause his prolonged symptoms, he would need to have sustained a perilymph fistula, with a resultant unilateral hearing loss, not the symmetric high frequency loss demonstrated on his audiograms." Thus, the examiner finds that the evidence leads to a different explanation of the pertinent in-service symptoms: "Rather than barotrauma, I think he had severe motion sickness. He stated that he returned from Korea to USA on a ship and he had the same off balance, nausea and vomiting the entire trip of thirty days." In summary, the July 2012 VA examination report concludes (1) that the Veteran's current vertigo since 1999 is due to unilateral vestibular loss that is (2) unlikely to be related to the Veteran's military service, and that (3) the Veteran's in-service symptoms were not indicative of barotrauma. The examiner's conclusions were informed by review of the claims-file as well as examination and interview of the Veteran. The discussion of each conclusion explained the pertinent factual bases and presented a persuasive analytical rationale for each conclusion. The Veteran's records obtained from the SSA do not contain any new records with new pertinent information supporting the Veteran's claim nor any information contradicting any findings or factual predicates discussed in the pertinent probative evidence in this case. Legal Criteria and Analysis Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Service connection also may be granted for any disease initially 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). To establish a claim of service connection, there must be evidence of a present disability; evidence of an in-service incurrence or aggravation of a disease or injury; and evidence of a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). When 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 each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). It is not in dispute that the Veteran now has chronic vertigo. It is also not in dispute that he was hospitalized in August 1962 for flu-like symptoms in service and experienced motion sickness. What he must still show to establish service connection for his chronic vertigo is that the current disability is related to his service, such as to the August 1962 hospitalization. The record includes both medical evidence that tends to support the Veteran's claim of service connection for chronic vertigo and medical evidence that is against such claim. When evaluating this evidence, the Board must analyze its credibility and probative value, account for evidence which it finds to be persuasive or unpersuasive, and provide reasons for rejecting any evidence favorable to the appellant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The evidence that tends to support the Veteran's claim includes a March 2003 VA treatment record in which Dr. I.K., the Veteran's neurologist, notes that he reviewed the Veteran's service enlistment and separation reports of medical history and found that when the Veteran separated from service, he indicated he had problems when flying and disliked flying. Based upon this fact, Dr. I.K. stated, "This may indicate that [the Veteran] might have had some sort of change in health condition during [service] which caused him not to like flying (? cause vertigo). He states he flew in cargo planes with inadequate pressures in the cabin. Could that have caused barotrauma? I am speculating as I can't be sure here." This opinion, by the provider's own account, is speculative and inconclusive; therefore it is without probative value. See Obert v. Brown, 5 Vet. App. 30, 33 (1993) (holding that a medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish medical nexus; medical evidence that is speculative, general, or inconclusive cannot be used to support a claim). Similarly, the undated medical opinion received in March 2012 from J.J.O., D.O., is also speculative and inconclusive; it is similarly without probative value. The undated medical opinion states that "it is certainly plausible" that the current disability is the result of a barotrauma during service, explaining that he has "no other obvious etiology to hang [his] hat on and [that] he [has] no reason not to believe that what [the Veteran] has stated is actual and true." This opinion expresses mere possibility (or plausibility) without stating any actual probability of a medical nexus. The author has not apparently reviewed the pertinent contents of the claims-file, and in particular has not been informed of nor considered the alternative possible etiologies discussed in other medical expert opinions of record that address the Veteran's documented medical history. The Board finds that this undated medical opinion is not probative because it is speculative and inconclusive, and also because it is not informed by the pertinent and contrary information of record in the claims-file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). See also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (indicating most of the probative value of an opinion comes from its underlying reasoning, not just from mere review of the claims file, although that, too, has its importance if evidence in the file may affect the underlying basis of the opinion such as by revealing relevant facts). The Veteran has also submitted a March 2003 private treatment record from Dr. B.J.K. of the Geisinger Medical Group, who opined that the Veteran's chronic vertigo may have been caused or was probably exacerbated by the flight in service, which was followed by the Veteran's hospitalization. This opinion was based solely on history provided by the Veteran, and not on an independent review of the Veteran's entire medical record. See Prejean v. West, 13 Vet. App. 444, 448- 49 (2000) (finding that a physician's access to the claims file and the thoroughness and detail of the opinion are important factors in assessing the probative value of a medical opinion). Significantly, the Veteran reported to Dr. B.J.K. that he was hospitalized in service for vertigo and nausea, and that he had suffered from vertigo ever since service. However, the Veteran's STRs show that he was hospitalized in August 1962 for a flu-like syndrome, and that such diagnosis was premised on complaints of bilateral shoulder pain and elevated temperatures for two days. They also show that on physical examination, his ears were clear, his throat slightly red, and his submandibular nodes were palpable. They are silent as to symptoms of dizziness, nausea, or vertigo. While the Veteran may be competent to testify as to symptoms he experiences, such as dizziness and nausea (see Barr v. Nicholson, 21 Vet. App. 303 (2007); see also Horowitz v. Brown, 5 Vet. App. 217, 221-22 (1993) (lay statements are competent on in-service symptoms and postservice symptoms that later formed the basis of diagnosis of Ménière's disease, including dizziness, loss of balance, hearing trouble, stumble and fall, tinnitus, nausea)), his recollection of a remote event cannot overcome the contemporaneous clinical findings recorded in his STRs. Contemporaneous recorded medical data by their very nature have greater probative value than recollections of remote events (here, some 40 years later). In contrast, the July 2012 VA examiner's opinion is based on a review of the claims file and contains a rationale for the opinions provided. In opining that the record does not reasonably support finding that the Veteran suffered from barotrauma during service, the examiner cited the details of the symptoms and clinical findings documented on the pertinent August 1962 STRs and explained that any barotrauma significant enough to cause the prolonged symptoms featured in this case would have to involve a perilymph fistula with a unilateral hearing loss that is not consistent with the facts of this case. The examiner explains that the medical information of record is more consistent with finding that the Veteran had severe motion sickness during service. In opining that the Veteran's chronic vertigo symptoms are not related to his service, to include the August 1962 hospitalization therein, the July 2012 VA examiner explained that given the particular documented history and clinical findings for the pertinent current disability, it is "highly unlikely that the event in 1962 would smolder for thirty seven years and then cause a catastrophic event in 1999, resulting in complete disability." The VA examiner noted that vertigo is multifactorial and that the event in 1962 could have many other diagnoses completely unrelated to the 1999 event. The July 2012 VA examiner acknowledged the Veteran's description of having "the same off balance, nausea and vomiting" during "the entire trip of 30 days" from Korea to the USA by ship during service; the examiner accounted for these symptoms in explaining that the symptoms were more consistent with "severe motion sickness" rather than with barotrauma. The Board's vacated September 2009 decision relied, essentially, on the April 2009 VHA medical advisory opinion to deny the Veteran's claim, and the Veteran appealed that decision to the Court. In September 2011, the Court issued a memorandum decision which found the April 2009 VHA medical advisory opinion to be inadequate because the VHA consultant failed to discuss significant facts from the Veteran's STRs. Specifically, the Court stated that when the VHA consultant "concluded that there was no evidence of barotraumas in service given the absence in the [STRs] of symptoms such as hearing loss, otitis media, vertigo, and nystagmus (rapid eye movement)," he did not refer to nor discuss "the evidence in the appellant's [STRs] that he suffered from motion sickness during service." Citing to an online medical dictionary, the Court observed that motion sickness is an illness that may be manifested by nausea, vomiting, and dizziness (vertigo). "Therefore, contrary to [the VHA consultant's] report there was evidence in the appellant's [STR] that could show he had vertigo during service." The Court also found the VHA consultant's medical opinion to be inadequate because it failed to "mention the appellant's repeated statements that he suffered from vertigo during his episodes of motion sickness in service." Notably, the Veteran is competent to testify as to observable symptoms. 38 C.F.R. § 3.159(a)(2); see also Layno v. Brown, 6 Vet. App. 465, 471 (1994) ("[C]ompetent testimony . . . is limited to that which the witness has actually observed, and is within the realm of his personal knowledge"). The Board notes that the identified inadequacies of the April 2009 VHA medical advisory opinion have been addressed by the July 2012 VA examination report. The July 2012 VA examiner presents an opinion, with explained rationale and direct reference to the Veteran's in-service motion sickness and vertigo, that it is unlikely that the Veteran had barotrauma during service and it is unlikely that in-service vertigo is related to the cause of the Veteran's current vertigo. Neither the July 2012 VA examination report nor the April 2009 VHA medical advisory opinion presents any opinion supportive of the Veteran's claim. The Board discounts the probative value of the August 2009 VHA medical advisory opinion as the September 2011 Court memorandum decision, the law of the case, found the opinion to be inadequate. The Board nonetheless reviewed it to determine whether, in the context of the other information of record, the opinion's discussion and rationale raise any significant contradictions of other evidence or otherwise may support the Veteran's claim. The Board finds that the contents of the August 2009 VHA medical opinion are consistent with the evidence and medical findings weighing against the Veteran's claim. In opining that the Veteran's chronic vertigo (and other postservice diagnoses) are not related to his service, to include the August 1962 hospitalization therein, the VHA consultant emphasized that the Veteran's STRs are silent for any otologic symptoms and that his ears were documented as normal. The VHA consultant acknowledged the Veteran's contemporaneous postcard in which he complained of ear pain, but noted that ear fullness, pressure, and pain frequently occur with altitude changes and does not necessarily indicate that the Veteran suffered from barotrauma in service. The VHA consultant's explanation that otitis media, hearing loss, and nystagmus are symptoms commonly associated with injuries resulting from barometric pressure changes, and noting that these symptoms are not shown in the STRs, is consistent with the July 2012 VA examiner's findings that the information of record did not support finding barometric trauma during service. The inadequacy of the VHA consultant's discussion was to overlook the possibility that the Veteran's in-service motion sickness implied symptoms of vertigo and that the Veteran has described recalling experiencing vertigo during that time; vertigo was also identified by the VHA consultant as a common symptom of barometric pressure injuries. The July 2012 VA examination report subsequently accounts for the Veteran's motion sickness and vertigo expressly while independently explaining that it is unlikely that the Veteran's in-service symptoms (including vertigo) represented barometric trauma. The VHA consultant explained that vertigo can be of central, peripheral, or combined origins. It was the examiner's opinion that the Veteran's June 1999 hospitalization for dizziness and double vision was related to the Veteran's brain, as he was diagnosed with right cerebellar syndrome, metastasis or bleeding ruled out, possible right small pontine lacunar stroke, and adjustment disorder not otherwise specified. As to the Veteran's November 2001 and November 2003 diagnoses of left vestibular weakness/loss, he opined that although peripheral in origin, these conditions were unrelated to the Veteran's service as there was no supportive documentation of imbalance/vertigo in the STRs. As to the 2002 diagnosis of left vestibular hypofunction, he opined that it was central in origin, as it was related to a mini-stroke. In evaluating medical opinions, the Board may place greater weight on one medical professional's opinion over another's depending on factors such as reasoning employed by the medical professionals, and whether or not and to what extent they review prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994). Here, the Board places greater weight on the July 2012 VA examiner's opinion as his opinion is based on a more accurate and complete factual background of the Veteran's service medical history and postservice clinical data. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (holding that "a mere conclusion by a medical [provider] is insufficient to allow the Board to make an informed decision as to what weight to assign to the [medical provider's] opinion"). Furthermore, the July 2012 VA examiner's opinion is supported by the evidence of record. Specifically, in September 2000, the Veteran's physician, Dr. V.B.N., opined that although the Veteran's brain MRI was negative, a possible small brain stem stroke affecting the vestibular nuclei could not be ruled out, and indicated that this was the likely reason for his symptomatology of dizziness, nausea, and double vision (rather than any remote trauma from service). In June 2002, it was Dr. Y.R.'s impression that the Veteran's left-sided vestibular hypofunction was the result of a mini-stroke he had sustained four years earlier (rather than any remote trauma from service). And, in November 2003, Dr. D.S. expressed doubt that a minor head strike or anything else that might have happened 40 years ago in service would have contributed to the Veteran's vestibular loss. The Board acknowledges that Dr. D.S. also allowed for the possibility that the Veteran may have suffered a partial vestibular loss on the left side while in service, which was compensated until he suffered a more recent loss of function, but notes that this was a speculative suggestion (and therefore lacking in probative value). Significantly, Dr. D.S. also sought to provide an alternative explanation for the Veteran's complaints by pointing to migraines, stating that the Veteran had a family history of such and that the quality of his headache complaints was consistent with migraines. On July 2007 VA examination, the examiner emphasized that although the Veteran states that he has had vertigo ever since service, his first documented vertiginous episode was in 1999, some 35 years after his separation from service. Such a lengthy period of time between service and the earliest postservice clinical documentation of the disability for which service connection is sought is of itself a factor for consideration against a finding that any current hearing loss is related to service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (in a claim alleging that a disability was aggravated by service). As to the Veteran's contention that he did not suffer from motion sickness until service (as is documented by his service separation report of medical history), and that his current diagnoses are related to such, the Board notes that, apart from the speculative opinion from Dr. I.K. in March 2003, none of the Veteran's extensive treatment records have associated his current diagnoses to motion sickness in service. The Veteran's own statements relating his current chronic vertigo to his service are not competent evidence, as he is a layperson, and lacks the training to opine regarding medical causation; this question is medical in nature and is not capable of resolution by lay observation. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). As the Board has found that the July 2012 VA examiner's opinion has more probative value than the March 2003 private opinions of Dr. I.K. or Dr. B.J.K. or the undated medical opinion from J.J.O., D.O., the Board concludes that the preponderance of the evidence is against the Veteran's claim. Accordingly, the benefit of the doubt doctrine does not apply; the claim must be denied. ORDER The appeal seeking service connection for a disability manifested by chronic vertigo is denied. ____________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs