Citation Nr: 1324470 Decision Date: 08/01/13 Archive Date: 08/13/13 DOCKET NO. 08-10 704 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUE Entitlement to service connection for hearing loss. REPRESENTATION Veteran represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD M.W. Kreindler, Counsel INTRODUCTION The Veteran served on active duty from July 1964 to July 1968. This matter came to the Board of Veterans' Appeals (Board) from a January 2007 rating decision of the Newark, New Jersey Department of Veterans Affairs (VA) Regional Office (RO). In a June 2009 decision, the Board denied the Veteran's claim of entitlement to service connection for hearing loss. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court). In March 2010, the Court granted a Joint Motion by VA and the Veteran to vacate the Board's decision, and remanded the case to the Board for action consistent with the Joint Motion. This matter was remanded in July2010, July 2011, and September 2011. FINDINGS OF FACT 1. Left ear hearing loss was not manifested during the Veteran's period of active service, did not manifest within a year of separation from service, and is not otherwise the result of a disease or injury during active service. 2. Right ear hearing loss is not currently shown. CONCLUSION OF LAW 1. Left ear hearing loss was not incurred in or aggravated by active service; nor may it be presumed. 38 U.S.C.A. §§ 1110, 1112, 1131 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303, 3.307, 3.309 (2012). 2. Right ear hearing loss was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1112, 1131, 5103A, 5107; 38 C.F.R. § 3.303, 3.385 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION 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 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). 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). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, the Veteran was sent a letter in October 2006 that provided information as to what evidence was required to substantiate the claim and of the division of responsibilities between VA and a claimant in developing an appeal, and the type of information and evidence needed to establish a disability rating and effective date. Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, to include substantial compliance with the Board remands (see D'Aries v. Peake, 22 Vet. App. 97, 105 (2008)), and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The previous remands were for the purpose of obtaining a VA examination and opinion. The Veteran was afforded two VA examinations which will be discussed below, but the examiners provided inadequate opinions. The Board then sought expert medical opinions from the Veterans Health Administration (VHA) which will be discussed below. See 38 C.F.R. § 20.901(a). The April 2013 VHA opinion remedied the deficiencies in the previous opinions. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The claims file contains the Veteran's service treatment records, post-service treatment records, and lay statements of the Veteran. The Board otherwise concludes that no available outstanding evidence has been identified pertaining to the hearing loss claim. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to this claim. The purpose of the JMR was for the Board to further consider the theory that the Veteran developed hearing loss as a result of injuries sustained when he was reportedly attacked by three people using pipes. Thereafter, the Board sought several medical opinions on this question and attempts to fully consider the theory in this decision. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Criteria & Analysis Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. 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 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498 (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. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element 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). In adjudicating this claim, the Board must assess the Veteran's competence and credibility. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368- 69 (2005). In Barr v. Nicholson, 21 Vet. App. 303 (2007), the Court emphasized that lay testimony is competent if it pertains to matters that the witness has actually observed and is within the realm of the witnesses personal knowledge. See also 38 C.F.R. § 3.159(a)(2) (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). 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). Additionally, for veteran's who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as sensorineural hearing loss due to an organic disease of the nervous system, are presumed to have been incurred in service if such manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a), 3.309(a). With chronic diseases shown as such in service, or within the presumptive period after service, so as to permit a finding of service connection, subsequent manifestation of the same chronic disease at any later date, however remote, are service connected unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). 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(b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Hearing loss is considered to be a disability for VA purposes when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition thresholds using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Factual Background & Analysis The service treatment records reflect the Veteran's hearing was normal upon entering service. There is no record of complaint or treatment for hearing loss or head trauma in service. His July 1968 discharge examination showed a whispered voice test to be 15/15. The ears were reported to be normal. Post-service private treatment records reflect that the Veteran gave no complaint or indication of hearing problems during physical examination at Newark Beth Israel Medical Center in December 1996. On examination of the eye, ear, nose and throat, the only reported finding was blurred vision. Private treatment records dated as late as May 1998 record no complaints of hearing loss. In March 1999, he informed his physician that he "still could not hear from his left ear." He was referred to an ENT physician. On evaluation later that month an ENT physician reported that there had been one incident of noise exposure in November 1998 when a pressurized hydraulic machine made a loud noise next to his left ear and he had noticed diminished hearing since that incident. He also had left-sided tinnitus. At a March 2000 consultation, the Veteran reported a history of exposure to industrial noise from working with hydraulic pumps and water jets, and exposure to artillery and other military noise. A February 2000 MRI revealed an acoustic neuroma on the left side. A second MRI in September 2000 confirmed the location and size of the acoustic neuroma. A December 2004 specialist consultation report records that the Veteran had had left ear hearing loss for six or seven years. He complained again in October 2006 that he could barely hear out of his left ear. An acoustic neuroma was again noted in his private medical records in October 2006 and October 2007. In October 2006, the Veteran wrote that he noticed a significant loss of hearing shortly after his discharge from the Navy, "as well as family and friends." He added that he was "unable to acquire citations because at the time I didn't have resources to consult a doctor or specialist to treat and document my disability." The Veteran was afforded a VA audiological examination in December 2006 with a chief complaint of hearing loss in the left ear, with onset 12 years earlier. He told the examiner that during Vietnam he was exposed to 5-inch gun blasts without ear protection. He also reported occupational noise exposure through his 25-30 year career as a pipe cleaner and recreational noise exposure through use of power tools. He reported that he wore ear protection during both activities. The examiner also noted that the Veteran reported a head injury during service. The Veteran reported that he had been "jumped by three people and hit in the head with pipes" during service in Vietnam. The Veteran alleged that the beating incident had an effect on his hearing. See Veteran's July 2007 Authorization and Consent to Release Information to the VA and April 2007 Notice of Disagreement. However, there is no documentation of the incident in the Veteran's service treatment records. An audiogram showed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 10 15 15 LEFT 30 45 60 60 55 Speech recognition ability was 100 in the right ear. Speech recognition ability in the left ear was too unreliable to score. The examiner concluded that the Veteran's hearing in the right ear was clinically normal, but hearing in the left ear exhibited mild to moderately severe hearing loss. The VA examiner reviewed the Veteran's claims file and medical records. He noted that the discharge examination revealed low frequency hearing sensitivity; no high frequency ear-specific audiometric data was available. The examiner opined that the Veteran's hearing loss was less likely than not (less than a 50/50 probability) caused by or a result of noise exposure during service, including service as a Gunner's Mate Striker in Vietnam. In explaining his rationale, the examiner noted there was a lack of supporting evidence in the claims file. The examiner noted that the reported development of hearing loss 8 years after service was not consistent with acoustic trauma. He also noted that the Veteran's current unilateral hearing loss was not consistent with bilateral noise exposure. In August 2010, the Veteran underwent a VA examination. Audiological testing revealed the following puretone thresholds: HERTZ 500 1000 2000 3000 4000 RIGHT 15 10 10 15 10 LEFT 35 50 75 65 60 The August 2010 audiologist opined that the Veteran's hearing loss was most consistent with an acoustic neuroma which was not related to noise exposure. He reasoned that the acoustic neuroma was diagnosed 36 years after the Veteran's discharge from service and there was no clinical evidence or reports that it was present while he was in the military. There was no hearing test conducted at the time of the Veteran's discharge. Therefore, it could not be stated with complete certainty that there was no noise-related hearing loss upon discharge. Thus, it could not be definitely stated that there was no noise-related component of the Veteran's left ear hearing loss. In July 2011, the examiner who conducted the August 2010 VA examination reviewed the Veteran's medical records and opined that the Veteran's hearing loss was not caused by or a result of his reported head injury caused by an assault with a metal pipe. He reasoned that a review of scientific literature did not reveal any studies concluding that head trauma had a correlating, causative effect on acoustic neuroma. The examiner who conducted the August 2010 VA examination had not reviewed the Veteran's claims file at the time he provided the July 2011 opinion. Therefore, in October 2011 he again reviewed the Veteran's medical records, including his claims file, and opined that his hearing loss was not likely ("less likely than not"/"less than 50 percent probability") incurred in or caused by an in-service disease or injury. This opinion was based on the fact that the acoustic neuroma was not identified until over 35 years after the Veteran's discharge from service. There was no evidence of any report of an assault in his service treatment records. The examiner added that although it was understandable that a solider would not report an assault, it was reasonable to assume that any trauma severe enough to cause a skull fracture or brain concussion would have been evaluated, treated, and documented. The examiner further reasoned that there was no medical evidence associating acoustic neuroma with head trauma, especially if the trauma occurred decades earlier. Acoustic neuroma occurred in the general human population, usually with no known cause. The only condition known to cause acoustic neuroma was neurofibromatosis, which was not associated with trauma. Thereafter, another opinion was sought as the August 2010 VA examiner had not provided an adequate opinion as to whether a relationship exists between the acoustic neuroma of the left ear and noise exposure in service. Again, the examiner could not definitively state that there was no noise-related component of the Veteran's left ear hearing loss. In March 2012, a VA otalaryngologist initially opined that it was not likely ("less likely as not") that the Veteran's hearing loss was related to his conceded noise exposure in service, but that it was likely ("likely as not") that it was related to his reported head trauma in service or was otherwise the result of a disease or injury in service. With regard to the opinion that the hearing loss was not related to in-service noise exposure, the physician reasoned that the Veteran reported hearing loss had begun eight years following service. He had sustained bilateral noise exposure without hearing protection while in service, but only experienced unilateral hearing loss. The physician further opined that it was likely ("at least as likely as not") that the Veteran's current left-sided hearing loss was caused by a diagnosed acoustic neuroma of the left ear. However, it was not likely ("less likely as not") that the acoustic neuroma had its onset in service, was related to noise exposure in service, was related to a reported head trauma in service, or was otherwise the result of a disease or injury in service. This opinion was based on the fact that the Veteran had not reported any hearing loss in service and that the physician was unaware of any medical literature that supported a relationship between acoustic neuroma and head trauma or noise exposure. In light of the fact that the physician who provided the March 2012 opinion had provided inconsistent opinions as to whether the hearing loss was related to head trauma in service and did not consider medical literature submitted by the Veteran that supported a possible relationship between acoustic neuroma and noise exposure, he re-reviewed the Veteran's claims file in May 2012. He initially opined that it was likely ("at least as likely or not") that the Veteran's left ear hearing loss was related to his reported head trauma in service. This opinion was based on the fact that the Veteran had experienced unilateral head trauma and ultimately developed unilateral hearing loss. The physician further stated, however, that he was unable to give an opinion without speculation as to whether the Veteran's acoustic neuroma had its onset in service, was related to the conceded noise exposure in service, or was related to previous head trauma or any other disease or injury in service. He explained that speculation on this matter was out of the realm of his expertise as a General Otalaryngologist and that the expert opinion of a Neuro-Otologist would be necessary to render an accurate opinion without speculation on these matters. Although the March and May 2012 opinions reflect that the Veteran's left ear hearing loss is related to his acoustic neuroma, they are inconsistent as to whether the acoustic neuroma and resulting hearing loss are related to his in-service head trauma. Thereafter, in an undated opinion, a VA neurological surgeon opined that the profound unilaterality of the left ear hearing loss argues for the acoustic neuroma as the source of hearing loss. The physician further explained, however, that the question of whether the Veteran's left ear hearing loss is caused (in whole or in part) by the diagnosed acoustic neuroma of the left ear is outside the scope of practice of a neurological surgeon and should be referred to a neuro-otologist. With regard to whether his acoustic neuroma had its onset in service, is related to the conceded noise exposure in service, was related to the reported head trauma in service, or was otherwise the result of a disease or injury in service, the neurological surgeon explained that in spite of decades of speculation on the connection between acoustic neuromas and environmental factors such as trauma and excess noise, including in the medical literature, no causal relationship (vs. correlation) has ever been established between acoustic neuromas and environmental factors. Thus, the physician opined that it is less likely than not that the acoustic neuroma is related to the conceded noise exposure in service, is related to the reported head trauma in service, or is otherwise the result of a disease or injury in service. The neurological surgeon stated that the question of whether the Veteran's current left ear hearing loss is due to a cause other than acoustic neuroma of the left ear (in whole or in part) is outside the scope of his practice as a Neurological Surgeon and should be referred to a neuro-otologist. Although the neurological surgeon's opinion suggested that his left ear hearing loss was related to his acoustic neuroma and opined that his acoustic neuroma was less likely than not due to noise exposure and head trauma in service, the physician stated that the questions were outside the scope of practice of a neurological surgeon. In April 2013, a VA otolaryngologist reviewed the Veteran's claims folder, to include the medical records, literature, and prior expert opinions. The examiner explained that his practice was limited exclusively to the subspecialty of Otology and Neurotology. The examiner opined that the Veteran's current left ear hearing loss was at least as likely as not (greater than 50 percent probability) caused by the diagnosed acoustic neuroma of the left ear. The examiner explained that acoustic neuroma was a known cause of unilateral loss and was a necessary consideration in the work-up of patients presenting with unilateral hearing loss. The Veteran was evaluated by a private otolaryngologist in March 1999 upon his referral from his primary care physician. At that time he reported left-sided hearing loss and intermittent tinnitus in the left ear. He also reported that the hearing loss had been present since November 1998 following an incident of noise exposure when a pressurized hydraulic machine made a loud noise next to his left ear. The examiner noted an MRI performed in February 2000 that showed a 6.0 to 8.0 mm acoustic neuroma on the left. A follow-up scan had been performed in September 2000 and showed an 8.0 mm acoustic neuroma on the left that was unchanged since the prior study. In December 2004, he reported to a physician that he had had hearing loss in the left ear for 6 to 7 years. An audiogram showed normal hearing on the right and a moderately severe-to-severe hearing loss on the left. This history along with the physical and radiographic findings was diagnostic of unilateral hearing loss caused by an acoustic neuroma. The otolaryngologist noted the epidemiologic studies submitted in support of this Veteran's claim of acoustic neuroma being caused by noise exposure; but commented that they did not reflect the current state of opinion regarding the origin of acoustic neuromas, which are overwhelmingly regarded as the product of spontaneous genetic mutation, when they are not associated with autosomal dominant inheritance such as those seen in neurofibromatosis type 2. Noise exposure had not been associated with such mutations. The finding of normal hearing on the right was not consistent with a history of noise exposure which would have most likely caused hearing loss in both ears. The examiner concurred with the opinions offered previously by audiologists that the nature of the noise-exposure hearing loss associated with the firing of naval guns would tend to be bilateral and therefore not be implicated in a unilateral hearing loss. The examiner stated it was less likely than not (less than 50 percent probability) that the acoustic neuroma had its onset during the Veteran's service. The examiner also stated that it was less likely than not (less than 50 percent probability) that the Veteran's current left ear hearing loss is related to the conceded noise exposure in service. It was less likely than not (less than 50 percent probability) that the Veteran's current left ear hearing loss is otherwise the result of a disease or injury in service. At the time of separation from service in July 1968 the Veteran did not report any hearing loss or other injury nor was any noted by the examiner. The Veteran reported to one physician in March 1999 that the left sided hearing loss and tinnitus had been present since an episode of explosive noise exposure in November 1998. He reported to another physician in December 2004 that the hearing loss in the left ear had been present for 6 to 7 years. The record thus supports an onset of hearing loss in the late 1990's well after service which ended in 1968. Despite the conceded noise exposure in service, there was no evidence that the Veteran's left ear hearing loss was related to that exposure. As of late 2004 the Veteran had normal hearing in the right ear. Noise exposure severe enough to cause hearing loss will likely affect both ears. The otolaryngologist also noted the Veteran's report of in-service head trauma caused by a beating. There was no evidence of a report by the Veteran or a medical evaluation occurring at that time. The examiner commented that a head injury severe enough to cause a sensorineural hearing loss would almost certainly have resulted in medical care being sought due to loss of consciousness, skull fracture or bleeding. There was likewise no evidence of any other disease or injury while in service that would have resulted in hearing loss. The examiner stated that it was less than likely (less than 50 percent probability) that the Veteran's current left ear hearing loss was due to a cause other than acoustic neuroma of the left ear, either in whole or in part. However, if one were to accept that the Veteran's current left hearing loss were due to a cause other than acoustic neuroma of the left ear, in whole or part, it was less likely than not (less than 50 percent probability) that the left ear hearing loss had its onset in service. Accepting that same premise, it was less likely than not (less than 50 percent probability) that the left ear hearing loss is related to the conceded noise exposure in service. Accepting the same premise, it was less likely than not (less than 50 percent probability) that the left ear hearing loss is related to the Veteran's reported head trauma in service. Accepting the same premise, it is less likely than not (less than 50 percent probability) that the left ear hearing loss is otherwise the result of a disease or injury in service. The examiner concluded that it was difficult to assume within any standard of medical probability that the Veteran's left hearing loss was due to a cause other than acoustic neuroma of the left ear, either in whole or in part. Assuming, however, that were the case, it was less likely than not (less than 50 percent probability) that the left ear hearing loss had its onset in service; was related to the conceded noise exposure in service; was related to the Veteran's reported head trauma in service; or, was otherwise the result of a disease or injury in service for the reason's posited in the previous responses. Left ear The record shows that the Veteran has an acoustic neuroma on the left side and mild to moderately severe hearing loss in the left ear. The December 2006 audiological examination revealed pure tone thresholds in the left ear in excess of 40 decibels. Therefore, he has a current hearing loss disability in the left ear for VA purposes under 38 C.F.R. § 3.385. The Veteran has two theories of entitlement to service connection for left ear hearing loss. He asserts that he had noise exposure in service that caused his left ear hearing loss and he asserts that he sustained a head injury in service that caused his left ear hearing loss. Initially, the Board notes that where a Veteran engaged in combat, satisfactory lay evidence that an injury or disease was incurred in service will be accepted as sufficient proof of service connection where such evidence is consistent with the circumstances, conditions, or hardships, of service. 38 U.S.C.A. § 1154(b). Section 1154(b) sets forth a three step sequential analysis that must be undertaken when a combat Veteran seeks benefits under the method of proof provided by the statute. First, it must be determined whether the Veteran has proffered "satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease." Second, it must be determined whether the proffered evidence is "consistent with the circumstances, conditions, or hardships of such service." Finally, if the first two requirements are met, VA "shall accept the Veteran's evidence as sufficient proof of service connection," even if no official record exists of such incurrence exists. In such a case a factual presumption arises that that the alleged injury or disease is service connected. Collette v. Brown, 82 F.3d 389, 393 (Fed. Cir. 1996); 38 C.F.R. § 3.304 (1996). Evidence of a current disability and of a nexus between service and a current disability is still required. Wade v. West, 11 Vet. App. 302 (1998); Turpen v. Gober, 10 Vet. App. 536 (1997); Libertine v. Brown, 9 Vet. App. 521 (1996). The Veteran's DD 214 reflects a military specialty of Boatswains Mate (BM 0100). Service aboard ships and exposure to gunfire is consistent with his duties in service. Hence, his reports of in-service noise exposure are competent and credible. One of the reported in-service injuries, is therefore, established. Assuming arguendo that 38 U.S.C.A. § 1154(b) is applicable; and the evidence would still need to show a link between the current disability and in-service noise exposure. The Veteran's reports of an in-service assault are also competent. He would certainly be capable of reporting that he was attacked. This report; however, does not appear credible. As VA physicians have noted, the Veteran reported a very serious attack, but also reported that he received no pertinent medical treatment. The medical experts have expressed strong doubt that such a serious attack could occur without the need for medical treatment. The Veteran also left service with no residuals being noted on the separation examination, and did not report the attack during post-service medical treatment. For these reasons, his relatively recent reports of an in-service attack are not deemed credible. The outcome turns on whether there is a link between the in-service injuries and the current hearing loss. The Veteran reported in his August 2006 claim that hearing loss started in 1976, eight years after leaving service. He reported a similar history to a VA examiner. Treatment records report the onset of hearing loss in the 1990's. As noted earlier, the Veteran did report on one occasion that he noted hearing loss "shortly" after discharge from service; he has never specifically reported the onset of symptoms prior to 1976. The lack of any complaint or clinical treatment for hearing loss for many years after service weighs against a finding that the disability was present during service or in the year immediately after service. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Absent evidence of ongoing hearing loss dating from service, the evidence is against finding a continuity of symptomatology. There are multiple medical opinions as to the relationship between the current hearing loss and in-service noise exposure or head trauma. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. Nieves-Rodriguez, 22 Vet. App. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also 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"). The October 2006 VA examiner opined that the Veteran's hearing loss was less likely than not due to the result of noise exposure during service, including service as a Gunner's Mate Striker in Vietnam. However, it is not clear that the examiner adequately considered his acoustic neuroma, thus such opinion is entitled to limited probative weight. The August 2010 VA examiner opined that the Veteran's hearing loss was most consistent with an acoustic neuroma which was not related to noise exposure, but then could not definitively state that there was no noise-related component of the Veteran's left ear hearing loss. While this examiner later reviewed the claims folder and provided addendum opinions regarding his claimed head trauma, the examiner did not offer any further statements regarding any relationship to noise exposure in service. Thus, such opinion cannot be accepted in support of or against the claim. As detailed, the March 2012 VA otolaryngologist opined that the Veteran's left ear hearing loss was not due to noise exposure in service based on the reasoning that he sustained bilateral noise exposure in service, but only sustained unilateral hearing loss eight years following service. But on later review, the examiner indicated that an opinion could not be given without resort to speculation. Thus, the opinion weighs neither for nor against the claim. Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009). As detailed the VA neurological surgeon opined that his acoustic neuroma was not due to the conceded noise exposure in service, as the medical literature did not support a causal relationship, but also indicated that it was outside his area of expertise. Thus, the Board will not accept this opinion as negative evidence against the claim. The April 2013 otolaryngologist explained that the Veteran's hearing loss is due his diagnosed acoustic neuroma of the left ear, but opined that his hearing loss was not due to noise exposure in service. The examiner explained that acoustic neuromas are overwhelmingly regarded as the product of spontaneous genetic mutation and noise exposure has not been associated with playing a role in promoting such mutations. The examiner also noted that the finding of normal hearing on the right is not consistent with a history of noise exposure which would have most likely caused hearing loss in both ears. The examiner concurred with prior opinions that the nature of noise exposure hearing loss associated with the finding of naval guns would tend to be bilateral and therefore not be implicated in a unilateral hearing loss. Based on the above, the Board finds that the probative evidence does not support a relationship between his hearing loss and noise exposure during service. The Board accepts the April 2013 VHA examiner's opinion as being the most probative medical evidence on the subject as such examiner is an expert in the field of otolaryngology, the opinion was based on a review of all historical records, and contains detailed rationale for the medical conclusions. See Boggs v. West, 11 Vet. App. 334 (1998). Given the depth of the examination report, and the fact that the opinion was based on a review of the applicable record, the Board finds such opinion is probative and material to the Veteran's claim. See Owens v. Brown, 7 Vet. App. 429 (1995). With regard to whether his left ear hearing loss is due to his purported head trauma in service, the August 2006 VA examiner did not address this assertion. As detailed, the August 2010 VA examiner opined that his acoustic neuroma was not associated with head trauma, especially if the trauma occurred decades earlier, and it would be reasonable to assume that any trauma severe enough to cause a skull fracture or brain concussion would have been required medical treatment. While the March 2012 VA opinion was proffered by an otalaryngologist, as detailed the examiner provided conflicting opinions. While the March 2012 examiner initially indicated that "it was likely" that his left ear hearing loss was related to his reported head trauma in service, in the rationale portion of the opinion indicated that it was not related to the reported head trauma in service. Upon subsequent review of the claims file, the examiner provided a positive etiological opinion relating his unilateral hearing loss to unilateral head trauma. But then, the examiner stated that an opinion could not be given without resort to speculation. Thus, in light of the examiner's conflicting statements and in light of qualifying his positive etiological opinion with the statement that an opinion cannot be made without resorting to speculation, the Board cannot accept this statement as positive evidence in support of the claim. The Veteran's representative argues that the Board should accept the favorable portions of the March 2012 opinion and grant service connection for left ear hearing loss; but this would require that the Board ignore the deficiencies in the opinion, including its contradictions; and also ignore the more probative opinion provided by the otolaryngologist in April 2013. The Board finds the April 2013 otolaryngologist's opinion to be the most probative evidence due to his expertise, review of the entire record, definitive opinion, and detailed rationale supporting that opinion. Nieves-Rodriguez. As the examiner explained, the Veteran's left ear hearing loss was due to acoustic neuroma and that it was less likely than not due to any in-service cause, to include the reported head trauma and noise exposure in service. The examiner indicated that a head injury severe enough to cause a sensorineural hearing loss would have almost certainly resulted in medical care being sought due to loss of consciousness, skull fracture or bleeding, but there is no evidence of such. There is otherwise no medical evidence that has been presented to indicate that the Veteran's hearing loss is the result of an in-service disease or injury, to include noise exposure or head trauma. The Board has also considered the Veteran's contention that a relationship exists between his hearing loss and in-service noise exposure and reported head trauma. The Veteran does not have the requisite medical expertise to say that hearing loss demonstrated years after service is due to a remote in-service cause as opposed to heredity or a post-service event. His opinion in this regard is not competent. Despite sustaining noise exposure and a purported head injury in service, consideration was given to this by VA examiners, but the most probative evidence of record is to the effect that his hearing loss is not due to service. The April 2013 VHA examiner considered the in-service noise exposure and head injury, and post-service symptomatology, to include specifically the acoustic neuroma, in forming a negative etiological opinion. Thus, the weight of the evidence indicates that left hearing loss is not due to his active service. In conclusion, the preponderance of the evidence is against a finding that the Veteran's left ear hearing loss is causally related to the Veteran's active service. Thus, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Right ear As detailed, service connection for impaired hearing is subject to 38 C.F.R. § 3.385, which provides that impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies of 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. For the purposes of applying the laws administered by VA, the thresholds for normal hearing are between 0 and 20 decibels, and higher thresholds show some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). For the right ear, none of the auditory thresholds in any of frequencies from 500 through 4000 Hertz are 40 decibels. None of the auditory thresholds for at least three of the frequencies (500, 1000, 2000, 3000, or 4000 Hertz) are 26 decibels or greater. Finally, the speech recognition score is not less than 94 percent. Consequently, in this case, the Veteran's hearing is within normal limits in the right ear. 38 C.F.R. § 3.385. In this regard, Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C.A. §§ 1110; see also Brammer v. Derwinski, 3 Vet. App. 223 (1992). In other words, in the absence of proof of present disability, in this case impaired hearing in the right ear per § 3.385, there can be no valid claim. The post-service examinations show that the Veteran does not have hearing loss in the right ear as defined by § 3.385. The Veteran has not specifically contended that he has hearing loss that would meet the regulatory definition and it would require audiologic testing to determine that he had hearing loss at the requisite level. As there is no probative evidence of a hearing loss disability in the right ear during service and following service in this case, as defined by the applicable regulation, the claim of service connection for right ear hearing loss must be denied. As a disability is not shown, the first element of a service connection claim has not been met, and thus it is not necessary to discuss an etiological relationship to service. The Board acknowledges the statements and testimony from the Veteran with respect to his noise exposure experienced during service. However, even conceding that the Veteran had noise exposure during service and even if his assertions were found credible, the fact remains that he does not have a disability of the right ear for VA purposes. As the preponderance of the evidence is against the claim of service connection for right ear hearing loss disability, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107. (CONTINUE ON NEXT PAGE) ORDER Entitlement to service connection for hearing loss, left ear, is denied. Entitlement to service connection for hearing loss, right ear, is denied. ____________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs