Citation Nr: 18157020 Decision Date: 12/11/18 Archive Date: 12/11/18 DOCKET NO. 13-32 012 DATE: December 11, 2018 ORDER 1. The claim for entitlement to service connection for right ear hearing loss is denied. 2. The claim for entitlement to service connection for left ear hearing loss is denied. FINDINGS OF FACT 1. The Veteran’s pre-existing right ear hearing loss was noted on entry into active service, and was not aggravated beyond the normal progress of the disorder during military service. 2. Clear and unmistakable evidence demonstrates that the Veteran’s left ear hearing loss disability pre-existed his active service, and clear and unmistakable evidence demonstrates that the Veteran’s left ear hearing loss disability was not aggravated in service beyond the normal progress of the disorder. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for right ear hearing loss have not been met. 38 U.S.C. §§ 1110, 1111 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.385, 3.306 (2018). 2. The criteria for entitlement to service connection for left ear hearing loss have not been met. 38 U.S.C. §§ 1110, 1111 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.385, 3.306 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1974 to July 1974. This case comes before the Board of Veterans’ Appeals (Board) from an October 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas (hereinafter Agency of Original Jurisdiction (AOJ)). In November 2016, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Board videoconference hearing. A transcript of the hearing is associated with the claims file. In September 2017, the Board sought expert opinion from the Veterans Health Administration (VHA) on the issue of entitlement to service connection for bilateral hearing loss. The VHA opinion, dated November 2017, was provided to the Veteran and his representative. In April 2018, the Board remanded the appeal for additional development. The appeal has returned to the Board for appellate consideration. 1. Entitlement to service connection for right ear hearing loss 2. Entitlement to service connection for left ear hearing loss The Board may dismiss any appeal which fails to allege a specific error of fact or law in the determination being appealed. 38 U.S.C. 7105 (2012). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. 20.204 (2018). Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. 20.204. Withdrawal of a claim is only effective where the withdrawal is explicit, unambiguous, and done with a full understanding of the consequences of such action on the part of the claimant. DeLisio v. Shinseki, 25 Vet. App. 45, 57 (2011) (“Although Mr. DeLisio ‘thought’ that the Board member had identified the issues to be discussed, the transcript reflects neither an explicit discussion of withdrawal nor any indication that Mr. DeLisio understood that he might be withdrawing claims for benefits for any disabilities not discussed.”). In a written statement received in March 2018, the Veteran wrote on a copy of a VA examination report that “[t]he left ear is the only ear I am claiming for.” However, in the context of the entire record, it remains unclear whether the Veteran is pursuing a bilateral hearing loss claim even after this statement. As the record does not reflect a clear and unambiguous withdrawal with an understanding of the consequences, the finds that the criteria for withdrawing the appeal as to the issue of service connection for right ear hearing loss have not been met. Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. As organic diseases of the nervous system, including sensorineural hearing loss, are considered to be chronic diseases for VA compensation purposes, if chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support a finding of chronicity. 38 C.F.R. 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. 3.303(d). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including organic diseases of the nervous system such as sensorineural hearing loss, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Every veteran is presumed to have been in sound condition upon entry into service except as to defects, infirmities, or disorders noted at the time of entry. 38 U.S.C. 1111; 38 C.F.R. 3.304(b). In order to rebut the presumption of soundness, it must be shown with clear and unmistakable evidence that a disorder preexisted service and that the disorder was not aggravated by service. Id. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). A “[h]istory of preservice existence of conditions recorded at the time of examination does not constitute a notation of such conditions....” 38 C.F.R. § 3.304(b)(1); see also Crowe v. Brown, 7 Vet. App. 238, 245 (1994). Where the presumption of soundness has initially attached, the burden is on VA to rebut the presumption by clear and unmistakable evidence that the disease or injury was both preexisting and not aggravated by service. See, e.g., McKinney v. McDonald, 28 Vet. App. 15, 23 (2016) (citing Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004), Horn v. Shinseki, 25 Vet. App. 231, 234 (2012), and Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991)). VA is not precluded from determining that the presumption of soundness is rebutted, even if there is conflicting evidence. See Kent v. Principi, 389 F.3d 1380, 1383 (Fed. Cir. 2004) (“The clear and unmistakable evidentiary standard... does not require the absence of conflicting evidence.”). A determination that a condition had its onset prior to service may be supported by contemporaneous evidence or recorded history in the record which provides a sufficient factual predicate to support a medical opinion (Miller v. West, 11 Vet. App. 345, 348 (1998)), or a later medical opinion based on statements made by a veteran about the preservice history of the condition (Harris v. West, 203 F.3d 1347 (Fed. Cir. 2000)). A preexisting injury or disease is considered to have been aggravated by service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability was due to the natural progress of the condition. See Wagner, 370 F.3d at 1096 (holding that when no preexisting condition noted on entry to service, government may show lack of aggravation by establishing that any increase was due to the natural progress of the preexisting condition). In addressing the aggravation prong of the presumption of soundness, VA must rely on affirmative evidence to prove that there was no aggravation, rather than the notion that the record contains insufficient evidence of aggravation. See Horn, 25 Vet. App. at 235. 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 “clear and convincing” burden of proof, while a higher standard than a preponderance of the evidence, is a lower burden to satisfy than clear and unmistakable evidence). It is an “onerous” evidentiary standard, requiring that the no-aggravation result be “undebatable.” Cotant v. West, 17 Vet. App. 116, 131 (2003) (citations omitted). The threshold for normal hearing is from 0 to 20 decibels; higher thresholds show some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). For the purpose 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, 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 scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. In cases where there are conflicting statements or opinions from medical professionals, it is within the Board’s province to weigh the probative value of those opinions. In Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993), the Court stated: The probative value of medical opinion evidence is based on the medical expert’s personal examination of the patient, the physician’s knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches.... As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the adjudicators;... So long as the Board provides an adequate reason or basis for doing so, the Board does not err by favoring one competent medical opinion over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). The VA benefits system does not favor the opinion of a VA examiner over a private examiner, or vice versa. See 38 U.S.C. § 5125; White v. Principi, 243 F.3d 1378, 1381 (Fed. Cir. 2001) (declining to adopt the treating physician rule for adjudicating VA benefits). Regardless of the source, an examination report must minimally meet the requirement of being sufficiently complete to be adequate for the purpose of adjudicating the claim. See 38 U.S.C. § 5125; 38 C.F.R. § 4.2. A medical examiner’s review of the claims folder may heighten the probative value of an opinion, as the claims folder generally contains all documents associated with a veteran’s disability claim, including not only medical examination reports and service treatment records (STRs), but also correspondence, raw medical data, financial information, RO rating decisions, Notices of Disagreement, materials pertaining to claims for conditions not currently at issue and Board decisions disposing of earlier claims. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008). However, an examiner’s review of the claims folder is not required in each case. See Snuffer v. Gobber, 10 Vet. App. 400, 403-04 (1997) (review of claims file not required where it would not change the objective and dispositive findings made during a medical examination); see also D’Aries v. Peake, 22 Vet. App. 97, 106 (2008) (holding that it is not necessary for a VA medical examiner to specify review of the claims folder where it is clear from the report that the examiner has done so and is familiar with the claimant’s extensive medical history). A significant factor to be considered for any opinion is based on an accurate factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). Although formal rules of evidence do not apply in the VA benefits system, the Court has indicated that recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of the reasons for the adjudicator’s decision. Rucker v. Brown, 10 Vet. App. 67, 73 (1997). Within the VA benefits system, VA medical examiners and private physicians offering medical opinions in veterans’ benefits cases are essentially considered expert witnesses. Nieves-Rodriguez, 22 Vet. App. 295 (2008). In Nieves-Rodriguez, the Court indicated that the Federal Rules of Evidence for evaluating expert medical opinion before U.S. district courts, Fed.R.Evid. 702, are important, guiding factors to be used by VA adjudicators in evaluating the probative value of a medical opinion. The factors identified in Fed.R.Evid 702 are as follows: (1) The testimony is based upon sufficient facts or data; (2) the testimony is the product of reliable principles and methods; and (3) the expert witness has applied the principles and methods reliably to the facts of the case. Lay persons may provide competent testimony as to observable symptoms and manifestations of a disorder. Jones v. Brown, 7 Vet. App. 134, 137 (1994); Layno v. Brown, 6 Vet. App. 465, 469 (1994); Barr v. Nicholson, 21 Vet. App. 303 (2007); Buchanan v. Nicolson, 451 F.3d 1331 (Fed. Cir. 2006). A veteran can attest to factual matters of which he has or had first-hand knowledge, e.g., experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Federal Circuit has held that lay evidence is one type of evidence that must be considered, if submitted, when a veteran seeks disability benefits, and competent lay evidence can be sufficient in and of itself for proving the existence of a chronic disease. See Buchanan, 451 F.3d at 1335; 38 C.F.R. §§ 3.303(a), 3.307(b). The Board, however, retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. Buchanan, 451 F.3d at 1336. Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465 (1994) (distinguishing between competency (“a legal concept determining whether testimony may be heard and considered”) and credibility (“a factual determination going to the probative value of the evidence to be made after the evidence has been admitted”)); see also Barr v. Nicholson, 21 Vet. App. 303 (2007). The claimant bears the burden of presenting and supporting his/her claim for benefits. 38 U.S.C. § 5107(a). See Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009). In its evaluation, the Board shall consider all information and lay and medical evidence of record. 38 U.S.C. § 5107(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board shall give the benefit of the doubt to the claimant. Id. Another way stated, VA has an equipoise standard akin to the rule in baseball that “the tie goes to the runner.” Gilbert v. Derwinski, 1 Vet. App. 49 (1990). By reasonable doubt it is meant that an approximate balance of positive and negative evidence exists which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. The Veteran contends his hearing loss disability is due to an ear infection he developed in service due to prolonged exposure to water as part of motivational pit training. He also attributes his hearing loss to being yelled at by his superior officers. He asserts that he did not manifest hearing loss in either ear prior to entering service or, alternatively, that any pre-existing hearing loss worsened during service. A November 1973 enlistment examination showed that the Veteran had a bilateral hearing loss disability, per VA standards of 38 C.F.R. § 3.385, with pure tone values above 40 decibels (dBs) at 2000 and 4000 hertz (Hz). On his Report of Medical History, the Veteran denied a history of hearing loss. A January 1974 audiogram conducted at the time of entering active duty showed only a hearing loss disability in the right ear, per VA standards of 38 C.F.R. § 3.385, with pure tone values above 40 decibels at 2000 and 4000 Hz. The left ear, however, only showed 15 decibels at 4000 Hz and equivocal handwriting as to whether there was a 10 or 40 decibel pure tone value at 2000 Hz – the Board interprets this ambiguity in favor of the Veteran by accepting a lower 10 decibel value. On February 28, 1974, the Veteran was referred to the ear, nose and throat (ENT) service due to his report of ear pain with an inability to hear commands from the left side. A March 5, 1974 consultation noted that audiogram showed marked hearing loss in the left ear and moderate loss in the right. The examiner instructed that the Veteran should not be punished for problems related to his hearing loss, and retesting was scheduled. A March 12, 1974 audiological record showed right and left puretone values exceeding 40 decibels at 4000 Hz for both air conduction and bone conduction. There was a noted improvement of speech reception threshold (SRT) of 10 decibels on the right and 25 decibels on the left with the audiologist commenting a belief that the Veteran’s pure tone hearing was better than shown on audiogram. Nonetheless, the examiner stated that the Veteran had a definite high frequency loss and needed earplugs when on the firing range. There was also a question of low (tone) frequency hearing loss. A March 19, 1974 ENT service record noted that repeat audiogram showed bilateral hearing loss greater than the minimum retention in the military noting “(however some inconsistency). At any rate – this most likely represents a true loss.” The examiner recommended audiogram testing to be performed on 3 consecutive days with consideration of a medical discharge. That day, the Veteran had two separate audiometric tests performed. One of the tests noted that SRT and air conduction (AC) did not coincide with the examiner stating “undoubtedly has ↓ hearing in L ear, but as to severity, it’s questionable until audiogram improves. Was re-instructed [with] minimal improvement.” A March 21, 1974 audiological report commented that the results were “questionable !!” On the next day, the audiologist commented that the results were “??” After a consultation with the audiologist, the ENT service recommended that the Veteran should be medically discharged for bilateral sensorineural hearing loss which existed prior to service. A final audiogram on April 5, 1974 commented that the Veteran was “[s]low to respond!!” On April 5, 1974, a Medical Board determined that the Veteran manifested bilateral, partial deafness which existed before service and was not aggravated during service. It was noted that physical examination revealed clear auditory canals with the tympanic membranes free from perforations or evidence of chronic disease. The Veteran’s audiograms indicated a bilateral, high frequency hearing loss much greater on the left “[t]he severity is variable and somewhat inconsistent but ranges from 40 to 90 decibels at 2000 and 4000 frequency range.” It was indicated that the Veteran’s Armed Forces Examining and Entrance Exam (AFEES) indicated a bilateral high frequency hearing loss, more pronounced in the left ear.” It was noted that the Veteran did not recall having a hearing problem prior to enlistment. In a rebuttal statement, the Veteran described his hearing as “satisfactory” prior to enlistment, and described the onset of ear pain after being yelled at by drill instructors with “a very loud and shrill tone.” He described that, when first sleeping in his barracks, he could be kept awake by small, inoffensive noises such as unauthorized whispering. However, after the noise exposure and sharp ear pains started – mostly on the left – he could shut out the distracting night time noises by turning his right ear to the pillow. He noted that a medical officer had recommended his protection from noise exposure, but he described continual exposure to loud noises by his drill instructors. A subsequent dermatology consultation noted that the Veteran was being discharged for left ear hearing loss with a reference to an untreated infection during recruit training. In March 2010, the Veteran’s private physician submitted a letter indicating that the Veteran’s military records indicated that he had a severe ear infection caused by prolonged water exposure which clearly resulted in hearing loss. It was indicated that the Veteran’s medical records indicate some hearing loss prior to service, but the infection/incident clearly made the Veteran’s hearing much worse. In an April 2013 VA examination, the examiner found it was less likely than not that the Veteran’s hearing loss was caused by or the result of military noise exposure. The examiner further noted that the Veteran exhibited sensorineural hearing loss which is not the type of hearing loss that an ear infection would result in. A September 2015 VA examination also noted similar findings. A February 2016 private physician opinion referred to the Veteran’s left ear hearing loss as being caused by the Veteran being submerged under water for a prolonged period of time. In September 2017, the Board sought expert opinion from an otolaryngologist with the VHA to further address the etiology of the Veteran’s hearing loss. In November 2017, the VHA otolaryngologist stated there was clear and unmistakable evidence that the Veteran manifested left ear hearing loss disability when he entered service, as noted on his pre-enlistment audiologic testing. In so finding, the VHA expert noted these findings were verified by the Medical Board during their review. The VHA expert further opined there was clear and unmistakable evidence that the Veteran’s left ear sensorineural hearing loss was not aggravated in service beyond the normal progress of the disorder, including as a result of the claimed left ear infection. The examiner further opined that it was less likely than not that the Veteran’s right sensorineural hearing loss was aggravated beyond the normal progress of the disorder during service. A review of the examination report reflects that the examiner extensively reviewed the STRs, including the Veteran’s statements in service regarding an untreated ear infection during recruit training. The examiner also took into account the Veteran’s recollections to his private examiner of having his ears submerged in water for prolonged periods of time during “motivation pit” training. The examiner noted that three different type of hearing loss existed: conductive hearing loss which was caused by a mechanical hearing system problem (the outer ear, the ear canal, the tympanic membrane and the ossicles (also known as the “ear bones”; sensorineural hearing loss which was caused by a problem of the hearing organ (cochlea) or the hearing nerve (the vestibular nerve also known as cranial nerve VIII); or a combined conductive and sensorineural hearing loss. It was noted that the mechanical and nerve systems were both tested during an audiogram and recorded as separate marks, and that comparison of the marked results could determine the type and severity of hearing loss as well as reliability of the test. It was also noted that audiogram testing reliability depended upon the effort put in by the patient with typical signs of an unreliable audiogram including pure tones not coinciding with speech reception thresholds, pure tone thresholds varying more than +/- 5 decibels from tests administered within a short time frame, pure tone thresholds which vary inconsistently from one test to another, and air conduction thresholds that are better than bone conduction thresholds. The VHA examiner noted the multiple audiometric testing conducted in service with the unreliability of results found as noted by the examiners. The VHA examiner also found the reliability of audiogram responses during and after service to be poor based on several factors: 1) pure tones not coinciding with speech reception thresholds which was typically seen when the person tested responded to the tester’s speech instructions at a sound level that was quieter than the pure tones they could hear as seen on the audiograms of March 12th, 19th, and 21st; 2) test results which fell outside the variation of +/- 5 db in pure tone testing on different days or by different testers which was the “wiggle room” that accounted for interpretation of test results rather than inadequate or unreliable patient responses as seen on the testing between November 1973 and April 1974; 3) air conduction testing which was more sensitive (a lower dB number on the audiogram) than bone conduction test results as this was physically impossible and only seen in unreliable patient responses as seen on the audiograms performed on March 12th and 21st and April 5th, and; 4) the improvement of right and left ear testing found between in-service testing and post-service test results of April 2013, September 2014, and September 2015 noting there is no expectation of improvement of hearing levels over decades of time but, rather, maintaining the level of hearing loss or a deterioration. The VHA expert also addressed the Veteran’s private physician’s March 2010 opinion indicating the Veteran’s ear infection in service worsened any pre-existing hearing loss that he had. The expert noted the opinion was written by a family medicine provider and not an otolaryngologist or audiologist. The expert further noted the opinion was written without any first-hand knowledge of the infection and was based solely on the Veteran’s voiced history. Additionally, the VHA expert noted that there was no medical evidence to support that an ear infection, resulting from being submerged in water, can cause a sensorineural hearing loss which is the type of hearing loss the Veteran was found to have both prior to service and in recent audiograms. It was observed that otitis externa (also known as swimmer’s ear) can cause reversible conductive hearing loss when the infection subsided and the swelling and/or debris resolved. A medical treatise indicated that cranial nerve involvement was not associated with simple otitis externa. The VHA examiner also considered the Veteran’s description of noise trauma from his drill instructors during service. It was noted that human shouting measured at approximately 88 decibels which was below the typical threshold of 120 decibels of pain from sound, and there was no medical literature which supported the view that human yelling could cause hearing loss. In February 2018, the Veteran reported to a private ENT specialist of hearing loss which started in basic training after a left ear injury, that he had been denied initial treatment, and was subsequently told he had a busted eardrum requiring treatment. The ENT specialist found asymmetric hearing loss worse in the left ear “that was damaged while in basic training.” In considering the evidence of record under the laws and regulations as set forth above, the Board finds that service connection is not warranted for bilateral hearing loss. Initially, the Board notes that the Veteran’s November 1973 induction examination showed the Veteran had a bilateral hearing loss disability per VA standards at 2000 and 4000 Hz. A repeat audiogram conducted at enlistment continued to show right ear hearing loss per VA standards with repeated audiograms during service continuing to show right ear hearing loss per VA standards. The Board finds that a pre-existing right ear hearing loss was noted upon entry into service and, as such, the presumption of soundness does not apply to right ear hearing loss. With respect to the left ear, the audiogram taken on the date of enlistment did not show left ear hearing loss per VA standards at 2000 and 4000 Hz. This has some probative value tending to show that left ear hearing loss did not manifest before service. As such, the Board cannot find that left ear hearing loss was noted at entry based solely on the November 1973 audiogram. Thus, the presumption of soundness applies. 38 U.S.C. § 1111. However, the testing subsequent to January 1974 did show left ear hearing loss per VA standards at 2000 and 4000 Hz with military audiology and ENT specialists noting inconsistency in test results. When considered in light of the November 1973 audiogram also showing hearing loss per VA standards, the Board finds a conflict of evidence regarding the pre-existence of left ear hearing loss per VA standards which it is not competent to resolve on its own. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (holding that the Board may not base a decision on its own unsubstantiated medical conclusions). To resolve this discrepancy, the Board obtained opinion from a VHA otolaryngologist. This expert reviewed and discussed the reliability of the multiple audiograms performed in service citing 4 specific types of discrepancies which had also been noted by the audiologists and ENT specialists in service. The examiner also reviewed the post-service audiogram results. Overall, the VHA specialist found that clear and unmistakable evidence demonstrated that left ear sensorineural hearing loss per VA standards pre-existed service as shown by the pre-induction examination in 1973 when compared to all audiometric testing in service. The Board places significant probative weight on this finding as it was based on an extensive review of the entire evidentiary record, including the audiogram at the time of induction. The Board also observes that all audiograms performed during service after the January 1974 testing where interpreted by military examiners as showing left ear hearing loss worse than the right. The Medical Board specifically found that left ear hearing loss existed prior to service. Thus, while the January 1974 audiometric examination provides some evidence that left ear hearing loss did not exist prior to service, the January 1974 audiometric results itself without further analysis – given the November 1973 audiogram and subsequent audiograms - does not make it undebatable that left ear hearing loss did not exist prior to service. The Board has also considered the Veteran’s own descriptions of hearing loss, or lack thereof, prior to service. In service, the Veteran denied knowledge of any hearing loss prior to service, and self-described noticing hearing problems after being yelled at by drill instructors. The Veteran is competent to report his own perception of hearing acuity which has some probative value. However, his perception of having no hearing impairment prior to service does not adequately support a finding of no actual sensorineural hearing loss disability prior to service as the existence of a “disability” is specifically defined at 38 C.F.R. § 3.385 in terms of specific levels of tone threshold perceptions and speech recognition which is beyond lay competence to measure. McKinney v. McDonald, 28 Vet. App. 15, 24-5 (2016). The Board places greater probative weight on the VHA expert opinion interpreting the entirety of the record. The Board has also taken into consideration the private medical opinions which appear to relate the onset of hearing loss prior to service. It appears that the private physician in 2010 reviewed STRs. However, this examiner provided no analysis or rationale explaining the inconsistent audiometric results during service and, as such, the Board cannot discern from this opinion the basis for this assertion. The Board places greater probative weight to the VHA specialist opinion which evaluated each audiogram during service for reliability of results and interpretation as to the type of hearing loss manifested by the Veteran. As such, the Board finds that there is clear and unmistakable evidence that the Veteran’s left ear hearing loss preexisted his active service. The Board further finds that the Veteran’s pre-existing right ear hearing loss was not aggravated beyond the normal progress of the disorder during military service. Additionally, the Board finds that clear and unmistakable evidence demonstrates that the Veteran’s pre-existing left ear hearing loss disability was not aggravated in service beyond the normal progress of the disorder. The Medical Board report, based upon assessments by military audiologists and the ENT service, concluded that the Veteran’s bilateral hearing loss existed prior to service and was not aggravated therein. This assessment holds significant probative weight as it involves an evaluation of the Veteran by medical specialists during service. This opinion is supported by the opinion of the April 2013 VA examiner who reached a similar conclusion based upon review of the entirety of the record. More importantly, the VHA specialist concluded that right ear hearing loss was not aggravated beyond the normal progress of the disorder during service, and that clear and unmistakable evidence demonstrated that left ear hearing loss was not aggravated during service beyond the normal progress of the disorder. This opinion was based upon a separate evaluation of each audiometric test during service and cited 4 specific types of discrepancies which had also been noted by the audiologists and ENT specialists in service. This opinion is afforded great probative weight. On the other hand, the Veteran has provided opinion from a family physicians in 2010 and 2016 opining that the Veteran’s hearing loss was worsened by his in-service ear infection caused by prolonged water exposure. These opinions hold some probative value as the examiners appear to have had benefit of review of the claims folder. The probative value is lessened as the examiners did not provide any rationale, and is further weakened by the analysis provided by the VHA examiner. The VHA examiner opined that the Veteran manifested a sensorineural hearing loss which, per medical literature, would not be caused or aggravated by an ear infection. Rather, the ear infection would have resulted in a conductive hearing loss which had not been demonstrated on audiometric testing. The private examiner opinions do not distinguish between conductive and sensorineural hearing loss and, notably, do not explain the medical board findings that physical examination of the ears revealed clear auditory canals with the tympanic membranes free from perforations or evidence of chronic disease. The Board finds that the VHA opinion holds substantially greater probative weight than these private medical opinions. The Board also has reviewed a February 2018 assessment by a private ENT specialist who found asymmetric hearing loss worse in the left ear “that was damaged while in basic training.” This examiner is not shown to have specific knowledge of the STR contents, but appears solely based on the Veteran’s reported history of hearing loss which started in basic training after an untreated left ear injury for which, he had been told, caused a busted eardrum. The STRs not a history of infection, but there is no notation of a busted eardrum. Rather, as noted above, physical examination at the time of separation showed the Veteran’s tympanic membranes to be free from perforations or evidence of chronic disease. The Board finds that the VHA opinion holds substantially greater probative weight than this private medical opinion as it was based on the entirety of the record, including the Veteran’s accepted report of an ear infection with an analysis of how that infection would not have resulted in sensorineural hearing loss – the type of hearing loss shown in service and currently. In reading the VHA opinion as a whole and in the context of the evidence of record, the Board finds that the examiner’s determination, which addressed the central medical issues in this case, was based on an analysis of the evidence and current medical understanding, and is entitled to much greater probative weight than the private medical opinions. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (providing that an examination is not rendered inadequate where the rationale provided by an examiner “did not explicitly lay out the examiner’s journey from the facts to a conclusion”); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (stating that medical reports must be read as a whole and in the context of the evidence of record). The examiner was informed of the relevant facts regarding the Veteran’s medical history, including the prior positive medical opinion of record. He discussed pertinent evidence and based his opinion on audiologic principles, which allows the Board to make a fully informed determination. The Board has also considered the Veteran’s own description of hearing problems and self-assessment as to cause. As discussed above, his perception of the onset or worsening of hearing is greatly outweighed by the objective testing procedures performed by military specialists who found both right and left ear sensorineural hearing loss. His description of an ear infection has been accepted as true by the VHA examiner. He is deemed competent to relate being told that he had a “busted eardrum” but the probative value is lessened as it is unclear how accurate his recollection of a medical fact is based against a record which includes a finding at separation that his tympanic membranes were free from perforations or evidence of chronic disease. In any event, the probative weight of this evidence is greatly outweighed by the VHA examiner opinion which determined that an ear infection would have resulted in a conductive hearing loss, for which there is no medical opinion or assessment that the Veteran either manifested in service or currently manifests. Otherwise, the Veteran is not competent to speak to the issue of the type of hearing loss he manifests or to its cause, origin or onset. Consequently, the Board finds that service connection is not warranted for right and/or left ear hearing loss. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, that doctrine is not applicable in the instant appeal, and his claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Rasool