Citation Nr: 1328889 Decision Date: 09/10/13 Archive Date: 09/17/13 DOCKET NO. 12-20 923A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for tinnitus REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Jeanne Schlegel, Counsel INTRODUCTION The Veteran served on active duty from September 1956 to September 1960. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in May 2011 by the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. In May 2013, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Board videoconference hearing. A transcript of the hearing is of record. Relevant to these proceedings, in Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the VLJ who chairs a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. A review of the hearing transcript on file reflects that these matters were raised and discussed. In addition, the VLJ sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claim. Moreover, neither the Veteran nor his representative have asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), or otherwise identified any prejudice in the conduct of the hearing. As such, the Board finds that consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board can adjudicate the claim based on the current record. The Board notes that at and following the hearing, the Veteran presented additional evidence for the file, some of which was discussed at the hearing, which was accompanied by a waiver. A September 2013 review of the Veteran's paperless claims file does not reveal any additional documents pertinent to the present appeal. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. Bilateral hearing loss was not present in service, manifested within one year of the Veteran's discharge from service, or shown to be causally or etiologically related to any disease, injury, or incident in service. 2. Tinnitus was not present in service or shown to be causally or etiologically related to any disease, injury, or incident in service. CONCLUSIONS OF LAW 1. Bilateral hearing loss was not incurred in or aggravated by active service, nor may it be presumed to have been incurred in or aggravated by service. 38 U.S.C.A. §§ 1101, 1112, 1116, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2012). 2. Tinnitus was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminary Matters: VA's Duties to Notify & to Assist The Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012), 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012), requires VA to assist a claimant at the time that he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of what they must do to substantiate their claims. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). Specifically, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that the claimant is to provide; and (3) that VA will attempt to obtain. See Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements) The RO informed the Veteran of VA's duty to assist him in the development of evidence pertinent to his service connection claims in a letter dated in December 2010, issued prior to the initial unfavorable May 2011 rating decision, wherein the Veteran was advised of the provisions relating to the VCAA. In this regard, he was notified of the evidence and information necessary to substantiate his service connection claims. The Veteran was further advised that VA would assist him with obtaining relevant records from any Federal agency, which may include medical records from the military, from VA hospitals (including private facilities where VA authorized treatment), or from the Social Security Administration. With respect to private treatment records, the letter informed the Veteran that VA would make reasonable efforts to obtain private or non-Federal medical records, to include records from State or local governments, private doctors and hospitals, or current or former employers. Furthermore, the VA included copies of VA Form 21-4142, Authorization and Consent to Release Information, which the Veteran could complete to release private medical records to the VA. The Board further observes that the United States Court of Appeals for Veterans Claims (Court) issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The Veteran was provided with notice of the type of evidence necessary to establish a disability rating or effective date as was discussed in the Dingess case in December 2010, prior to the adjudication of the claims in May 2011. The Board also finds that all of the relevant facts have been properly developed, and that all available evidence necessary for an equitable resolution of the issues on appeal has been obtained. The Veteran's service treatment records (STRs) were obtained. Lay statements, photographs, Board hearing testimony, as well as private medical evidence was presented for the file, and the Veteran did not identify any relevant post-service treatment sources for his claimed hearing loss and tinnitus. VA's duty to assist includes obtaining an examination and medical opinion when necessary to make an adequate determination. See Duenas v. Principi, 18 Vet. App. 512 (2004). During the appeal period, a VA audio examination was conducted in February 2011, and an addendum opinion was provided in April 2011. The Veteran has not alleged that this examination was inadequate. See Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011), (in the absence of a challenge to the adequacy of the examination, the Board is not required to explicitly explain why each medical opinion is adequate). Moreover, the Board finds that the 2011 VA examination and opinion are adequate to address the service connection claims as the VA examiner provided a complete rationale, relying on, and citing to, the records reviewed in order to offer clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion . . . must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claims. Service Connection - Hearing Loss and Tinnitus In November 2010, the Veteran filed original service connection claims for bilateral hearing loss and tinnitus, indicating that both conditions began in January 1961. His DD 214 reflects service with the United States Air Force assigned to a fighter interceptor squadron and with a military occupational specialty (MOS) of weapons systems mechanic. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease 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). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, including organic diseases of the nervous system, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. In an October 4, 1995, opinion, VA's Under Secretary for Health determined that it was appropriate to consider high frequency sensorineural hearing loss an organic disease of the nervous system and therefore a presumptive disability. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki,708 F.3d 1331 (Fed. Cir. 2013). The threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 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. 38 C.F.R. § 3.385. The Court has held that service connection can be granted for a hearing loss where the Veteran can establish a nexus between his current hearing loss and a disability or injury he suffered while he was in military service. Godfrey v. Derwinski, 2 Vet. App. 352, 356 (1992). The Court has also held that VA regulations do not preclude service connection for a hearing loss which first met VA's definition of disability after service. Hensley, supra, at 159. 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; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The STRs include an enlistment examination report of September 1956 which revealed that whispered voice hearing testing was 15/15. A separation examination report of August 1960 also revealed that whispered voice hearing testing was 15/15. Clinical evaluation of the ears was normal and there was no mention of tinnitus or hearing loss. The Veteran denied having symptoms of running ears, or any ear trouble. In a lay statement dated in November 2010, the Veteran explained that during active duty he worked on the flight line as a radar mechanic on fighter jets, during which time he was constantly exposed to high frequency sounds on the flight line. He mentioned that there was no hearing protection offered during that time and that he knew for a fact that his hearing loss was related to acoustic trauma in service. In January 2011, the Veteran's spouse presented a lay statement for the file indicating that she married the Veteran in 1959 and that since his time in service, his hearing acuity had deteriorated. She mentioned that the Veteran kept the volume high on the television, had trouble hearing ordinary conversation, and needed her to repeat things said to him. She opined that the Veteran's hearing loss was due to his work on jet aircraft during service. A VA audio examination was conducted in February 2011. The Veteran reported that he first noticed hearing loss before 1960, which had gotten progressively worse. It was also reported that he had a 30+ year history of tinnitus, becoming louder and more constant. He gave a history of exposure to flight line noise while maintaining airplane electronics during service without hearing protection. He also gave a 15+ year history of target shooting with hearing protection, and a 20+ year history of hunting between 1989 and 2009, 1 time a year, without hearing protection. It was also noted that the Veteran complained of tinnitus and that this was as likely as not associated with hearing loss. Audiological examination revealed bilateral hearing loss meeting the threshold requirements of 38 C.F.R. § 3.385, described as asymmetric hearing loss, with speech recognition scores of 90 percent in the right ear and 62 percent in the left ear. The examiner indicated that no opinion could be provided without review of the claims folder. In a addendum provided in April 2011, the VA examiner indicated that the claims file had been received and reviewed. The examiner observed that whispered voice testing was normal on enlistment and separation from service and that records were silent for indications of hearing loss until 50 years later. The Veteran's history of recreational noise exposure was noted and the examiner commented that the Veteran was at an age when presbycusis could occur. Due to the aforementioned factors, the examiner opined that it was less likely than not that the Veteran's hearing loss and tinnitus was related to his time in service. In September 2011, the Veteran provided photos of aircraft that he worked on in service, and indicated that he sustained substantial acoustic trauma from F-102 fighter aircraft, and Md-3 portable electric generators, without hearing protection. He indicated that post-service while on the target range, he always wore hearing protection. He further explained that he only hunted for 15 years and only on the first two days of buck season, during which time he "hardly ever" fired his rifle. The Veteran presented testimony at a Board video conference hearing held in May 2013. He indicated that he did not seek treatment for hearing loss until 2011, when he first sought disability benefits. He stated that he noticed hearing loss while still in service. His representative mentioned that post-service the Veteran was employed as a lab technician, and did not sustain noise exposure as a civilian employee. In May 2013, additional evidence was provided for the file which was accompanied by a waiver. This evidence includes a September 2012 ENT report indicating that the Veteran gave a 40 year history of hearing loss, reported that this began to occur soon after service. It was noted that he spent a long time working around aircraft and loud equipment without hearing protection. He reported that most of the loud equipment was on his left side, and that his left hear hearing loss was worse. It was also noted that the Veteran was a hunter and went shooting recreationally, wearing ear protection while target shooting, but not while hunting. It was noted that he did have bilateral tinnitus. Mild sloping to severe sensorineural hearing loss, worse in the left ear was diagnosed. The examiner commented that the Veteran's work and noise exposure during service significantly contributed to his hearing loss, especially due to the asymmetry of the equipment. It was explained that it was impossible to say how much hunting/shooting and presbycusis were contributing factors as well. The Veteran reiterated his contentions and testimony in a January 2013 statement. A. Hearing Loss With respect to the hearing loss claim, evidence of a currently manifested hearing loss has been presented. Specifically, upon VA audiological evaluation conducted in 2011, bilateral hearing disability as defined under 38 C.F.R. § 3.385, was shown. Additionally, the Veteran has reported experiencing significant acoustic trauma in conjunction with his service in the United States Air Force. The Veteran is considered competent to describe noise exposure sustained during service and his statements to this effect are considered credible. Barr v. Nicholson, 21 Vet. App. 303 (2007). Therefore, the Board finds that the Veteran experienced exposure to excessive noise in service. The Board notes that essentially normal hearing was demonstrated in both ears as shown by the 1956 enlistment examination and 1960 separation examination report. Given such findings, the overall presentation revealed normal hearing bilaterally upon enlistment and separation from service, as was also concluded by the VA examiner as documented in the 2011 examination report. A hearing disability as defined under 38 C.F.R. § 3.385, was not shown during service, or at any time prior to 2011. Therefore, as bilateral hearing loss meeting the threshold requirements of 38 C.F.R. § 3.385 was not initially shown until 2011, more than 50 years after the Veteran's separation from service, service connection on a presumptive basis is not warranted. Pursuant to Walker, supra, the Board has considered whether the Veteran experienced continuity of bilateral hearing loss symptomatology since his service discharge. However, in this regard the Veteran has provided several different historical accounts. He has said that his hearing loss began while in service (2013 hearing testimony and 2011 VA examination report); in January 1961 (November 2010 original claims application); and soon after service (September 2012 ENT report). However, aside from the Veteran's somewhat inconsistent lay accounts, nowhere in the file has there been either lay or clinical presented revealing chronicity and continuity of hearing loss since 1960, when the Veteran was discharged from service. With regard to the decades-long evidentiary gap between active service and the earliest post-service findings of bilateral hearing loss, the lack of any evidence of continuing complaints, symptoms, or findings for many years between the period of active duty and the first evidence of bilateral hearing loss is itself evidence which tends to show that hearing loss has not been chronic and continuous since service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (noting that it was proper to consider the Veteran's entire medical history, including the lengthy period of absence of complaint with respect to the condition he now raised). In addition, assertions of long-term hearing loss were not presented until more than 50 years after the Veteran's discharge from service and only after he filed a service connection claim for hearing loss in late 2010. As such, there is reason to question the credibility of any lay information provided by the Veteran to the effect that the onset of his hearing loss was during or shortly after service and that it has been chronic and continuous since that time, particularly given the remoteness of acoustic trauma sustained between 1956 and 1960, and reports of a subsequent 20 year history of hunting without hearing protection. See Macarubbo v. Gober, 10 Vet. App. 388 (1997) (holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). Based on the total absence of any indications of hearing loss until 2011, more than 50 years after the Veteran's discharge from service, coupled with the absence of credible lay evidence or any clinical evidence revealing evidence of hearing loss in service, or post service between 1960 and 2010, chronicity and continuity of hearing loss since service is not established. Therefore, presumptive service connection for bilateral hearing loss is not warranted. The critical issue in this case is whether the Veteran's currently manifested bilateral hearing loss is related to noise exposure sustained during service. The requirement of an evidentiary showing of an etiological relationship has been repeatedly reaffirmed by the U.S. Court of Appeals for the Federal Circuit, which has held that a Veteran seeking disability benefits must establish the existence of a disability and a connection between the Veteran's service and the disability claimed. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). Although the Veteran was not treated for or diagnosed with bilateral hearing loss during service or for many years after his discharge, the Board notes that the question is whether this condition is nevertheless at least as likely as not etiologically related to service or any incident therein, to specifically include acoustic trauma sustained in service. 38 C.F.R. § 3.303(d). The record contains two medical opinions addressing this matter. Among the factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). In 2011, a VA examiner having recorded the Veteran's history of in-service and post-service noise exposure, his lay reports regarding hearing loss, and having reviewed the claims folder including the STRs, concluded that it was less likely that not the Veteran's bilateral hearing loss was caused by or the result of his military service. The examiner reasoned that the separation examination report failed to reveal any indication of hearing deficit during service, noted post-service and presbycusis as other pertinent factors, and relied on her clinical experience and expertise as a physician in rendering the determination. Presbycusis is a "lessening of hearing acuteness resulting from degenerative changes in the ear that occur especially in old age. . .". Godfrey v. Brown, 8 Vet. App. 113, 120-21 (1995). This opinion is found to carry significant weight, as it was based on a comprehensive review of the lay and clinical evidence on file dated from the Veteran's period of service, forward; and was supported by both clinical evidence pertaining to the specific case as well as medical expertise. See Nieves-Rodriguez, supra; Stefl, supra. Therefore, Board finds no adequate basis to reject this competent medical opinion based on a lack of credibility or probative value, and finds the opinion to be of significant probative value. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997); Evans v. West, 12 Vet. App. 22, 26 (1998). In contrast, the file contains the includes a September 2012 ENT report indicating that the Veteran gave history of hearing loss, reporting that this began to occur soon after service. It was noted that he spent a long time working around aircraft and loud equipment without hearing protection. He reported that most of the loud equipment was on his left side, and that his left hear hearing loss was worse. It was also noted that the Veteran was a hunter and went shooting recreationally, wearing ear protection while target shooting, but not while hunting. It was noted that he did have bilateral tinnitus. Mild sloping to severe sensorineural hearing loss, worse in the left ear was diagnosed. The examiner commented that the Veteran's work and noise exposure during service significantly contributed to his hearing loss, especially due to the asymmetry of the equipment. It was explained that it was impossible to say how much hunting/shooting and presbycusis were contributing factors as well. The 2012 private opinion is of far lower probative value than the VA opinion of 2011. The United States Court of Appeals for Veterans Claims (Court) has held that a medical report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicolson, 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."). In this regard, the 2012 ENT report and opinion does not account for the fact that the Veteran's service-related acoustic trauma was extremely remote, occurring more than 50 years previously. In this regard, the medical statement does not reflect that any STRs were reviewed in conjunction with providing the opinion therein, and as such there is no indication that the Veteran's separation examination results were considered, nor the fact that hearing loss was not initially shown until more than 50 years post-service, both of which are significant facts in this case. Further it is entirely inconsistent that the examiner was able to pinpoint extremely remote service-related acoustic trauma as the most likely source of the Veteran's hearing loss, despite being clearly aware of more recent relevant factors including recreational noise exposure from hunting without hearing protection, and presbycusis, which were described as "impossible" to assess in terms of contributory factors to hearing loss. Finally, the Board observes that there is no basis for the statement in the report to the effect that the Veteran had a 40 year history of mod-severe bilateral hearing loss, particularly in the absence of any audiological tests conducted prior to 2011, as reported by the veteran himself in his 2013 testimony. The Board further observes that lay assertions from the Veteran and his spouse as to the etiology of his bilateral hearing loss (service related due to acoustic trauma sustained therein) are beyond their competence as a lay people to make and are not consistent with the objective evidence of record, which does not establish continuity and chronicity of hearing loss since service or a probative nexus opinion between currently manifested hearing loss and acoustic trauma sustained in service. See Davidson v. Shinseki, 581 F.3d 1313, (Fed Cir. Sept. 14, 2009); Jandreau v. Nicholson, 492 F.3d 1372 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Specifically, the question of causation, or the relationship between the Veteran's in-service noise exposure and his current hearing loss, involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence, as is the opinion of his spouse. Id.; see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Overall, the evidence is not in relative equipoise, as there is evidence of normal hearing acuity at separation from service in 1960, and a more than 50-year gap between the Veteran's discharge from service and indications of bilateral hearing loss meeting the threshold requirements of 38 C.F.R. § 3.385. Moreover, the most probative evidence of record addressing the etiology and onset of the Veteran's hearing loss weighs against service incurrence. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). The benefit sought on appeal is therefore denied. B. Tinnitus Tinnitus has been defined as "a noise in the ear, such as ringing, buzzing, roaring, or clicking." See Dorland's Illustrated Medical Dictionary 1714 (28th ed. 1994). See also Wanner v. Principi, 370 F.3d 1124 (Fed. Cir. 2004). In Charles v. Principi, 16 Vet. App. 370, 374-375 (2002), the Court specifically held that tinnitus is a condition which is capable of lay observation. See also Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Accordingly, it is within the Veteran's competency to identify symptoms of tinnitus and the condition is therefore established through the Veteran's lay reports. Moreover, the 2011 VA examiner noted the Veteran's complaints of tinnitus, although this was not technically clinically diagnosed. Pursuant to the facts in the case and the above discussion, the fact that the Veteran sustained acoustic trauma during service is established in this case. The clinical evidence includes STRs which are entirely negative for any mention of tinnitus or symptoms associated therewith. A separation examination report of 1960 reflects that the Veteran denied having running ears, or any ear trouble. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (holding that contemporaneous evidence has greater probative value than history as reported by the Veteran). Thereafter, the earliest documentation of tinnitus in a clinical record was dated in 2011, more than 5 decades after the Veteran's service separation, and coincident with his filing his original service connection claim for benefits. During the 2011 VA examination, the Veteran gave a 30+ year history of constant tinnitus, becoming more louder and constant with time; dating its onset to approximately 1980, or 20 years after service. He did not specifically report having chronicity and continuity of tinnitus symptoms since service during his 2011 VA examination or his 2013 hearing testimony. Moreover, the Board observes that the over 50-year period since service, which is negative for complaints or treatment relating to tinnitus and during which time the Veteran never filed a service-connected clam for tinnitus, is evidence that there has not been a continuity of symptomatology, and it weighs heavily against the claim. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (holding that VA did not err in denying service connection when the Veteran failed to provide evidence which demonstrated continuity of symptomatology, and failed to account for the lengthy time period for which there is no clinical documentation of his low back condition); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (noting that it was proper to consider the Veteran's entire medical history, including the lengthy period of absence of complaint with respect to the condition he now raised). In weighing the credibility, VA may consider interest, bias, inconsistent statements, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the Veteran. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Further, the Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 Vet. App. 1331 (Fed. Cir. 2006). In light of the: (1) lack of evidence of tinnitus during service or upon separation, (2) Veteran's vague, inconsistent, and unsubstantiated reports regarding the onset and chronicity of tinnitus, and (3) 5 decades long evidentiary gap without clinical indications or even complaints of tinnitus, the Board can find no plausible reason to afford any probative value to any lay assertions to the effect that tinnitus has been chronic and continuous since service. Moreover, even acknowledging the Veteran's account of sustaining military noise exposure as credible, there still must be competent evidence presented establishing a nexus or relationship between currently diagnosed tinnitus and his military noise exposure. A Veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000). Although the Veteran was not treated for or diagnosed with tinnitus during service or for many years after his discharge, the Board notes that the question is whether this condition is nevertheless at least as likely as not etiologically related to service or any incident therein, to specifically include acoustic trauma sustained in service. 38 C.F.R. § 3.303(d). The record contains one medical opinion addressing this matter. Among the factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). As explained above, in 2011, a VA examiner having recorded the Veteran's history of in-service and post-service noise exposure, his lay reports of a 30+ year history of tinnitus, and having reviewed the claims folder including the STRs, concluded that tinnitus was not at least as likely as not the result of military noise exposure. This opinion is found to carry significant weight, as it was based on a comprehensive review of the lay and clinical evidence on file dated from the Veteran's period of service, forward; and was supported by both clinical evidence pertaining to the specific case as well as medical expertise. See Nieves-Rodriguez, supra; Stefl, supra. Therefore, Board finds no adequate basis to reject this competent medical opinion based on a lack of credibility or probative value. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997); Evans v. West, 12 Vet. App. 22, 26 (1998). In addition, the Veteran has not provided any competent medical evidence to rebut this opinion or otherwise diminish its probative weight. See Wray v. Brown, 7 Vet. App. 488, 492-93 (1995). In this regard, no opinion relating to tinnitus was provided in the September 2012 ENT report. In addition, the lay assertions from the Veteran as to the etiology of his tinnitus (service related due to acoustic trauma sustained therein) are beyond his competence as a lay person to make and are not consistent with the objective evidence of record, which does not establish continuity and chronicity of tinnitus since service or a nexus between currently manifested tinnitus and acoustic trauma sustained in service. See Davidson v. Shinseki, 581 F.3d 1313, (Fed Cir. Sept. 14, 2009); Jandreau v. Nicholson, 492 F.3d 1372 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Specifically, the question of causation, or the relationship between the Veteran's in-service noise exposure and his current tinnitus, involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. Id.; see also Woehlaert, supra. Overall, the evidence is not in relative equipoise, as there is evidence of normal clinical evaluation of the ears at separation from service in 1960 without subjective complaints of any ear problems, and a more than 50-year gap between the Veteran's discharge from service and indications of tinnitus. Moreover, the most probative evidence of record addressing the etiology and onset of the Veteran's tinnitus weighs against service incurrence. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). The benefit sought on appeal is therefore denied. ORDER Service connection for bilateral hearing loss is denied. Service connection for tinnitus is denied. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs