Citation Nr: 1330506	
Decision Date: 09/23/13    Archive Date: 09/30/13

DOCKET NO.  09-43 906	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Waco, Texas


THE ISSUES

1.  Entitlement to service connection for bilateral hearing loss.  

2.  Entitlement to service connection for tinnitus.  


REPRESENTATION

Appellant represented by:	Texas Veterans Commission


WITNESS AT HEARING ON APPEAL

Veteran


ATTORNEY FOR THE BOARD

S. Keyvan, Counsel


INTRODUCTION

The Veteran had active service from March 1968 to March 1970.  

This matter comes to the Board of Veterans' Appeals (Board) on appeal from a June 2008 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO), in Waco, Texas, which, respectively, denied the Veteran's claims of service connection for bilateral hearing loss and tinnitus.  

During the current appeal, and specifically in April 2012, the Veteran testified at a videoconference hearing conducted before the undersigned.  A transcript of the testimony has been associated with the Veteran's claims file.  

In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim.  A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal.  

In April 2013, the Board remanded the Veteran's claims for additional evidentiary development and due process considerations.  Specifically, the Board requested that the Agency of Original Jurisdiction (AOJ) contact the Veteran and ask him to identify any VA and non-VA healthcare providers who may have provided treatment for his hearing loss and tinnitus.  The AOJ was also instructed to schedule the Veteran for another VA audiological evaluation to determine the nature and etiology of any hearing disorder and tinnitus that he may have.  In an April 2013 letter, the Veteran was asked to complete a VA Form 21-4121 medical release form for any non-VA provider who treated him for his hearing loss and tinnitus.  In May 2013, the Veteran responded to this request and provided copies of treatment records pertinent to the issues on appeal.  The Veteran was also scheduled for a VA examination in connection to his claims in June 2013.  This examination was completed, and a copy of the June 2013 VA examination report has been associated with the Veteran's claims file.  After completing the necessary development, the AOJ continued the denial of the claims for entitlement to service connection for bilateral hearing loss and tinnitus and these issues have now been returned to the Board for further appellate action.  


FINDINGS OF FACT

1.  Bilateral hearing loss was noted on the service pre-induction audiogram and thus, the Veteran's bilateral hearing loss pre-existed his entrance into active service.  

2.  Resolving reasonable doubt in favor of the Veteran, his bilateral hearing loss underwent an increase in severity beyond the natural progression of the disorder during active service.  

3.  Resolving reasonable doubt in favor of the Veteran, his tinnitus is related to noise exposure incurred during his military service.


CONCLUSIONS OF LAW

1.  Resolving reasonable doubt in the Veteran's favor, the Veteran's pre-existing bilateral hearing loss was aggravated during active service.  38 U.S.C.A. §§ 1110, 1111, 1112, 1153, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.385 (2013).  

2.  Tinnitus was incurred in service.  38 U.S.C.A. §§ 1110, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2013).  


REASONS AND BASES FOR FINDINGS AND CONCLUSION

I.  Duties to Notify and Assist

On November 9, 2000, the President signed into law the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, & 5126 (West 2002 & Supp. 2011)).  The VCAA imposes obligations on VA in terms of its duty to notify and to assist claimants.  The Board has considered the legislation regarding VA's duty to notify and to assist claimants but finds that, given the favorable action taken herein with respect to the issues of entitlement to service connection for bilateral hearing loss and tinnitus, no further discussion of the VCAA is required with respect to these claims.  See, e.g., Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92, 57 Fed. Reg. 49,747 (1992).  

II.  Analysis

Service connection may be established for a disability resulting from diseases or injuries which are clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 U.S.C.A. §§ 1110 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303 (2013).  Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability.  Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009).  

In accordance with 38 U.S.C.A. § 1154(a) VA must give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability benefits.  Medical evidence of a current disability and nexus is not always required to establish service connection.  See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009).  Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.  Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007).

Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions.  Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises.  It would also include statements contained in authoritative writings such as medical and scientific articles and research reports or analyses.  38 C.F.R. § 3.159(a)(1).  Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience.  Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person.  38 C.F.R. § 3.159(a)(2).  

Service connection for certain diseases, including organic diseases of the nervous system such as sensorineural hearing loss, may be also be established on a presumptive basis by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service.  38 C.F.R. §§ 3.307(a)(3), 3.309(a).  Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection.  The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid.  38 C.F.R. § 3.303(d) (2013).  

If a chronic disease is shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes.  38 C.F.R. § 3.303(b).  If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection if the disability is one that is listed in 38 C.F.R. § 3.309(a).  The Federal Circuit Court recently held that the theory of continuity of symptomatology under 38 C.F.R. § 3.303(b) does not apply to any condition that has not been recognized as chronic under 38 C.F.R. § 3.309(a).  See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).  

VA's General Counsel has held that to rebut the presumption of sound condition under 38 U.S.C.A. § 1111, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service.  The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches.  See VAOPGCPREC 3-2002; see also Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004).  

A pre-existing injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless clear and unmistakable evidence shows that the increase in disability is due to the natural progress of the disease.  See 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306 (2013).  "Clear and unmistakable evidence" is a more formidable evidentiary burden than the preponderance of the evidence standard.  See Vanerson v. West, 12 Vet. App. 254, 258 (1999) [noting that the "clear and convincing" burden of proof, while a higher standard than a preponderance of the evidence, is a lower burden to satisfy than that of "clear and unmistakable evidence"].  It is an "onerous" evidentiary standard, requiring that the pre-existence of a condition and the no-aggravation result be "undebatable."  See Cotant v. West, 17 Vet. App. 116, 131 (2003) citing Laposky v. Brown, 4 Vet. App. 331, 334 (1993).  

Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service.  See 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. §§ 3.304, 3.306(b) (2013).  A pre-existing disease or injury will be presumed to have been aggravated by service only if the evidence shows that the underlying disability underwent an increase in severity; the occurrence of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of a disability.  See Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); 38 C.F.R. § 3.306(a) (2013).

A finding of aggravation is not appropriate in cases where the evidence specifically shows that the increase is due to the natural progress of the disease.  Furthermore, temporary or intermittent flare-ups of a pre-existing disease during service are not sufficient to be considered aggravation of the disease unless the underlying condition, as contrasted to symptoms, worsens.  See Jensen v. Brown, 4 Vet. App. 304, 306-7 (1993); Hunt v. Derwinski, 1 Vet. App. 292 (1991).  

With respect to hearing loss, VA has specifically defined what is meant by a "disability" for the purposes of service connection.  See 38 C.F.R. § 3.385 (2013).  "[I]mpaired 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."  

The Board notes that the United States Court of Appeals for Veterans Claims (Court) has held that the threshold for normal hearing is from 0 to 20 decibels, and that higher threshold levels indicate some degree of hearing loss.  See Hensley v. Brown, 5 Vet. App. 155, 157 (1993).  

In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant.  See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990).  When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant.  38 U.S.C.A. § 5107(b).  When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant.  Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim.  38 C.F.R. § 3.102.  The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied.  See Gilbert, 1 Vet. App. at 54.

Bilateral Hearing Loss

The Veteran contends that his current hearing loss developed and worsened as a result of his in-service exposure to acoustic trauma while serving in the military.  In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that entitlement to service connection for bilateral hearing loss should be granted.  In making this determination, the Board highlights that the post-service medical evidence of record demonstrates that the Veteran has been diagnosed with bilateral hearing loss.  See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (noting that the requirement of a current disability is satisfied when the claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim).  Specifically, both VA audiological examination reports (which will be discussed in greater detail below) reflect that the Veteran is currently diagnosed with bilateral sensorineural hearing loss.  See May 2008 and June 2013 VA Audiological Examination Reports.  For reasons expressed below, the Board finds that the evidence of record establishes that the Veteran's hearing loss pre-existed his military service.  

Turning to the service treatment records, while the clinical evaluation of the Veteran's ears and drums was shown to be normal at the February 1965 pre- induction examination, on the authorized audiological evaluation, pure tone thresholds, in decibels, were:  




HERTZ



500
1000
2000
3000
4000
RIGHT
5(20)
0(10)
5(15)
10(20)
50(55)
LEFT
5(20)
5(15)
0(10)
5(15)
30(35)

[The Board observes that service department audiometric readings prior to October 31, 1967, must be converted from American Standards Association (ASA) units to International Standard Organization (ISO) units.  As these evaluations were conducted prior to October 1967, the Board has converted the ASA units (first threshold listed at each frequency) to ISO units (second threshold listed at each frequency) as shown below.]  

In addition, the Veteran was shown to have a hearing loss profile of 'H2' at the time of this examination.  Odiorne v. Principi, 3 Vet. App. 456, 457 (1992) (observing that the 'PULHES' profile reflects the overall physical and psychiatric condition of the Veteran on a scale of 1 (high level of fitness) to 4 (a medical condition or physical defect which is below the level of medical fitness for retention in the military service)).  

Based on the audiometric findings, the medical examiner determined that the Veteran had defective hearing, and noted as such in the Summary of Defects and Diagnoses section.  As previously discussed above, in order to rebut the presumption of soundness, there must be clear and unmistakable evidence that the Veteran's disorder preexisted service.  See VAOPGCPREC 3-2002.  While the Veteran's hearing loss was not considered to be disabling, and he was found fit for induction, there is sufficient medical evidence indicating that the Veteran's hearing loss preexisted his period of active duty.  Given the notation of hearing loss at the Veteran's enlistment examination, the presumption of soundness does not operate in the present case.  As such, the Board finds that his hearing loss existed prior to service.  Consequently, the relevant inquiry is whether the Veteran's hearing loss was aggravated, rather than incurred in, active duty service.  

At the March 1968 enlistment examination, the authorized audiological examination reflected pure tone thresholds, in decibels, as follows:




HERTZ



500
1000
2000
3000
4000
RIGHT
15
0
0
20
50
LEFT
5
5
0
5
50

The Veteran was once again shown to have a hearing loss profile of 'H2' at the time of this examination and the medical examiner noted that the Veteran had defective hearing in the Summary of Defects and Diagnoses section.  When comparing this examination report to the February 1965 examination findings, the Board acknowledges a slight increase in the Veteran's left ear auditory threshold at 4000 Hertz.  Regardless of the audiometric findings, the Veteran was deemed qualified for enlistment.  

Review of the March 1970 examination pursuant to the Veteran's discharge from service reflects that the Veteran did not undergo an audiological evaluation prior to his separation from service.  However, he was afforded a whispered voice test at separation, the findings of which were shown to be 15/15 in both ears.  

The relevant post-service records consist of the May 2008 and June 2013 VA audiological examination reports; the April 2012 audiometric report and May 2012 letter issued by the Veteran's private audiologist, J.C., Au.D.; statements submitted by the Veteran and his family members; and the April 2012 hearing transcript.  

During his hearing, the Veteran described experiencing a significant level of noise exposure while stationed in Vietnam, and specifically testified that he had exposure to extreme noises and sounds produced by the "Chinook helicopters" he was transported in while participating in numerous missions in Vietnam.  See April 2012 Hearing Transcript (T.), pp. 3-4.  

The Veteran is competent to describe what he experienced in service.  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 facts or circumstances and conveys matters that can be observed and described by a lay person.  38 C.F.R. § 3.159(a)(2).  Competency of evidence differs from weight and credibility.  The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted.  Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("Although interest may affect the credibility of testimony, it does not affect competency to testify.")  

A review of the Veteran's DD 214 reflects that his military occupational specialty (MOS) was that of firefighter and that he had eight months of foreign service.  The record also reflects that the Veteran received a Vietnam Service Medal and Republic of Vietnam Campaign Medal.  In the June 2008 rating decision, the RO granted the Veteran's claims for various other disabilities based on his service inside Vietnam and resulting exposure to Agent Orange.  Indeed, the Board can find no information in the claims file that calls into question the Veteran's statements about noise exposure while serving in Vietnam.  While every detail of the Veteran's description has not been corroborated, there is nothing in the record that specifically contradicts the Veteran's account of having been exposed to extreme noise levels in service.  Therefore, the Board concludes that the Veteran's description of noise exposure while serving in Vietnam during his period of service is credible, and concedes that the Veteran was exposed to extreme noise levels during service.  

At the May 2008 VA examination, the Veteran's audiometric findings were as follows: 




HERTZ



500
1000
2000
3000
4000
RIGHT
15
35
60
70
90
LEFT
20
45
65
85
95

Speech audiometry revealed speech recognition ability of 84 percent in the right ear and 80 percent in the left ear.  The Veteran was diagnosed with bilateral sensorineural hearing loss.  These findings meet the requirements of 38 C.F.R. § 3.385 (2013).  After reviewing the Veteran's claims file, the VA examiner noted that the Veteran had a pre-existing hearing loss at his February 1965 pre-induction and March 1968 enlistment examinations.  The examiner further noted that a formal audiological examination was not performed at the Veteran's March 1970 separation examination, and the whisper voice tests indicated that his hearing was within normal limits bilaterally.  According to the examiner, in light of the fact that a "formal audio[logical] exam was not performed at separation from active duty, an opinion regarding a hearing threshold shift while on active duty cannot be formed without resorting to speculation."  

The Veteran later submitted results from an April 2012 audiological evaluation that was conducted at a private treatment facility, and a May 2012 letter from the audiologist who performed this audiogram.  The results of this private audiometric testing showed pure tone thresholds, in decibels as follows:




HERTZ



500
1000
2000
3000
4000
RIGHT
20
35
65
75
95
LEFT
25
40
70
85
100

The private audiogram results were provided in graph form, and the Board has provided the numeric equivalents above based on the depiction of these findings.  See Kelly v. Brown, 7 Vet. App. 471, 474  (1995) (noting that, because interpreting results from an audiometric graph involves fact finding, the Court is precluded from engaging in such fact finding in the first instance, and remanding in part because the Board did not discuss the results of the private audiometric testing).  In the May 2012 letter, J.C. explained that the April 2012 audiometric findings revealed a borderline to profound high sensory neural hearing loss in both ears.  According to J.C., review of the Veteran's military records reflects that he had "a high frequency hearing loss in both ears when he entered the military."  J.C. further took note of the Veteran's reported exposure to excessive noise levels produced by "Chinook helicopters" while serving in Vietnam.  J.C. went on to explain that the whispered voice tests conducted at the separation examination were tests "commonly used in the military before calibrated audiometry was widely available" and are "inherently insensitive to the high frequency area of hearing which is most affected by noise exposure."  According to J.C., based on her evaluation of the Veteran, as well as her discussion with the Veteran regarding his in-service noise exposure in the military with a pre-existing hearing loss, "it is at least as likely as not that [the Veteran's] current hearing loss w as caused by or contributed to by noise exposure experienced during his military service."  

The Veteran was afforded another VA audiological evaluation in June 2013.  Based on her evaluation of the Veteran, as well as her review of the claims file, the examiner diagnosed the Veteran with bilateral sensorineural hearing loss and concluded that said hearing loss existed prior to service.  With respect to whether the Veteran's pre-existing hearing loss was aggravated in service, the examiner explained that the whispered voice test conducted at the March 1970 separation examination is insensitive to high frequency hearing loss, the type of hearing loss most commonly caused by noise exposure.  According to the examiner, "[w]ithout accurate audiometric data at separation, it is unknown if [the Veteran's] current hearing loss was aggravated by military noise exposure or the natural progression of hearing loss following separation. . . ."  Based on this understanding, the examiner determined that an opinion regarding a connection between the Veteran's hearing loss and noise exposure during military service cannot be rendered without resorting to mere speculation.  Although the examiner later indicated that the Veteran's pre-existing hearing loss was not aggravated during service, her reasoning in her rationale reflects that she could not provide a clear answer to this question without speculation.  

Accordingly, after carefully reviewing the evidence of record and resolving all reasonable doubt in his favor, the Board finds that the Veteran's pre-existing hearing loss did undergo an increase in severity beyond the natural progression of the disorder during active service.  In arriving at this decision, the Board relies on the Veteran's conceded noise exposure and the May 2012 opinion issued by J.C.  Indeed, the Board finds that the conclusion that the Veteran bilateral hearing was was "contributed to" by noise exposure experienced during his military service is equivalent to the Veteran's hearing loss being aggravated by his in-service noise exposure.  

With regard to the May 2008 and June 2013 medical reports, the Board finds these opinions to be of limited probative value to the extent that no definitive etiological opinion was provided as to the relationship between the Veteran's hearing loss and service.  Furthermore, neither examiner appears to have given much weight to the Veteran's account of his in-service experiences and his reported exposure to loud noise while carrying out his military duties.  In any event, the Board notes that, while the May 2008 and June 2013 examiners did not provide an opinion relating the Veteran's hearing loss to service, neither examiner stated in definitive terms that such disability is not related to his years in service.  

Unfortunately, because the Veteran was not given an audiogram hearing test at the time of service discharge, it is difficult to tell whether his hearing loss underwent an increase in severity during service.  However, in light of the Veteran's conceded in-service noise exposure, and the May 2012 opinion which provides an explanation as to why the whispered voice tests conducted upon separation are inaccurate devices in establishing whether the high frequency hearing level has been affected by noise exposure, and concludes that the Veteran's hearing loss did worsen as a result of his in-service noise exposure, the Board resolves reasonable doubt in favor of the Veteran, and finds that the Veteran's bilateral hearing loss did undergo an increase in severity during service that was beyond the normal progression of the disorder.  There is no evidence to the contrary.  Therefore, in giving the Veteran the benefit of the doubt, service connection for hearing loss is granted.  

Tinnitus

In considering the evidence of record under the laws and regulations concerning service connection, the Board concludes that the Veteran is entitled to service connection for tinnitus.  As previously discussed, the Veteran maintains that he was exposed to extreme noises and sounds produced by the helicopters he was transported around in during his period of service in the Republic of Vietnam.  The Board notes that findings from the February 1965 and March 1968 audiograms (as discussed in detail in the previous section) reflect that the Veteran had some level of high-frequency hearing loss upon enlistment.  However, the Veteran does not maintain that he experienced ringing in his ears prior to service, or that his tinnitus pre-existed his service.  Therefore, evidence of hearing loss on his enlistment examination report is not relevant with respect to his tinnitus claim.  

At the April 2012 videoconference hearing, the Veteran testified that he first began experiencing a ringing sound in his ears in service several months after he arrived in Vietnam.  See T., p. 4.  Statements made by the Veteran throughout the appeal indicate that he has continued experiencing tinnitus since his separation from service.  Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.  Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007), see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2007).  

The Board finds that the Veteran's statements with regard to this claim are credible.  Further, the Board notes that tinnitus is subjective, and the kind of condition to which lay testimony is competent.  See Charles v. Principi, 16 Vet. App. 370, 374 (2002) (finding Veteran competent to testify to symptomatology capable of lay observation).  Thus, the Board finds that the Veteran is competent to relate a history of noise exposure during service and a history of having experienced tinnitus.  

Moreover, the Board has granted the Veteran's request for service connection for bilateral hearing loss based, in part, on his description of his in-service exposure to acoustic trauma while performing his military duties.  That the Veteran has hearing loss adds to the credibility of his contention that he has tinnitus because "an associated hearing loss is usually present" with tinnitus.  The Merck Manual, Sec. 7, Ch. 82, Approach to the Patient with Ear Problems.  Concerning this matter, the Board notes that tinnitus may occur as a symptom of nearly all ear disorders including sensorineural or noise-induced hearing loss.  Id.  With regard to the latter, the Board has granted service connection for hearing loss in this case because the evidence is at least in equipoise that the hearing loss was noise-induced, i.e., the pre-existing hearing loss worsened as a result of his conceded exposure to acoustic trauma during service.  In this regard, the Board notes that "high frequency tinnitus usually accompanies [noise-induced] hearing loss."  The Merck Manual, Section 7, Ch. 85, Inner Ear.  

Here, the Veteran was afforded VA examinations in connection with his tinnitus claim in May 2008 and June 2013.  During the May 2008 examination, he reported that his tinnitus had its onset in 1973, several years after his separation from service.  Based on a review of the records, the audiological evaluation, and the Veteran's assertions, the examiner diagnosed the Veteran with tinnitus and concluded that said disorder is less likely than not related to his service.  The examiner appears to have relied on the Veteran's assertions that his tinnitus began subsequent to his service, and the absence of any documented complaints of tinnitus in the service treatment records, when reaching this conclusion.  

The Board acknowledges the examiner's concerns regarding the reported post-service date of onset, but notes that both prior to, and since, the May 2008 VA examination, the Veteran has consistently maintained that his tinnitus began in service.  Indeed, in his September 2007 claim, the Veteran stated that his hearing loss and tinnitus developed in service.  The May 2012 letter issued by J.C. reflects the Veteran's assertion that his tinnitus had its onset in service.  This contention was subsequently reaffirmed during his videoconference hearing, as discussed above.  Additionally, at the June 2013 VA examination, the Veteran relayed his military history and reported that he noticed his tinnitus in service.  Further, in reaching this opinion, the examiner does not appear to have given much weight to the Veteran's account of his in-service noise exposure in Vietnam.  As such, the Board finds this medical opinion to be of limited probative value.  

Furthermore, in the May 2012 letter, J.C. noted that the Veteran's "chronic and constant tinnitus" is a condition "commonly associated with hearing loss...[that] can [also] be aggravated by noise exposure."  Based on her review of the medical records, as well as her discussion with the Veteran regarding his in-service noise exposure, J.C. concluded that it was at least as likely as not that the Veteran's bilateral tinnitus was caused by noise exposure experienced during his military service.  

The June 2013 VA examiner determined that she could not provide a medical opinion concerning the etiology of the Veteran's tinnitus without resorting to speculation.  According to this examiner, in light of the inconclusive whispered voice hearing tests, and the absence of any documented complaints of tinnitus in the service treatment records, an opinion regarding a connection between the Veteran's tinnitus and his noise exposure in service cannot be rendered without resorting to mere speculation.  

Importantly, as previously discussed herein, the Board has conceded the Veteran's in-service acoustic trauma.  Furthermore, the cited provisions from The MERCK Manual confirm that tinnitus usually accompanies noise-induced hearing loss.  In other words, if a veteran has noise-induced hearing loss (as the Veteran here does as the evidence reflects that his pre-existing hearing loss worsened as a result of his in-service acoustic trauma), that person is likely also to have noise-induced tinnitus.  Importantly, the Board has determined that the Veteran's contention that he experiences tinnitus constitutes competent and credible evidence upon which the Board may rely in making its decision.  [As previously noted herein, the Veteran has contended that he has experienced a ringing sound in his ears since service.]  In addition, the Board notes that, while the June 2013 VA examiner did not provide an opinion relating the Veteran's tinnitus to service, she has not stated in definitive terms that such disability is not related to his years in service.  Furthermore, in the May 2012 opinion, J.C. also had an opportunity to interview and evaluate the Veteran, and review his medical records, and she did find that the Veteran's tinnitus was related to his in-service noise exposure.  

Without reaching a determination as to whether the Veteran's tinnitus was caused or aggravated by his now service-connected hearing loss, the fact remains that the evidence for and against the claim for service connection for tinnitus on a direct basis is at least in approximate balance.  Based on this record, the Board finds that the Veteran's tinnitus is as likely as not the result of his noise exposure in service.  Again, and of particular importance in this regard, are the facts that the Veteran's in-service noise exposure has been conceded and that he has provided competent and credible evidence (e.g., assertions) of ringing in his ears since service.  Accordingly, and based on this evidentiary posture, the Board will resolve reasonable doubt in favor of the Veteran and grant service connection for tinnitus.  38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102.




ORDER

Service connection for bilateral hearing loss is granted.

Service connection for tinnitus is granted.  




____________________________________________
THOMAS H. O'SHAY
Acting Veterans Law Judge, Board of Veterans' Appeals



Department of Veterans Affairs