Citation Nr: 18159350 Decision Date: 12/18/18 Archive Date: 12/18/18 DOCKET NO. 16-51 192 DATE: December 18, 2018 ORDER The petition to reopen a previously denied claim for entitlement to service connection for bilateral hearing loss is granted. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for a left knee disorder is denied. Entitlement to service connection for a right knee disorder is denied Entitlement to service connection for benign prostatic hypertrophy (BPH) is denied. REMANDED Entitlement to an initial compensable rating for chronic otitis externa is remanded. Entitlement to service connection for tinnitus, to include as secondary to chronic otitis externa, is remanded. Entitlement to service connection for depression, to include a sleep disorder and as secondary to chronic otitis externa and tinnitus, is remanded. Entitlement to service connection for drug and alcohol abuse is remanded. FINDINGS OF FACT 1. A February 1980 rating decision last denied service connection for bilateral hearing loss. 2. Evidence pertaining to the Veteran’s bilateral hearing loss since the last final rating decision was not previously submitted, relates to unestablished facts necessary to substantiate the claim, is neither cumulative nor redundant, and raises a reasonable possibility of substantiating the claim. 3. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of bilateral hearing loss for VA compensation purposes. 4. The preponderance of the evidence is against finding that a bilateral knee disorder, to include arthritis, began during active service or within one year of service, or is otherwise related to an in-service injury, event, or disease. 5. The preponderance of the evidence is against finding that BPH began during active service or within one year of service, or is otherwise related to an in-service injury, event, or disease. CONCLUSIONS OF LAW 1. The February 1980 rating decision that last denied service connection for bilateral hearing loss is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. The evidence received since the last final February 1980 rating decision is new and material, and the claim for service connection for bilateral hearing loss is reopened. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156, 20.1103. 3. The criteria for service connection for bilateral hearing loss are not met. 38 U.S.C. §§ 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.385. 4. The criteria for service connection for a left knee disorder, to include arthritis, are not met. 38 U.S.C. §§ 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309(a). 5. The criteria for service connection for a right knee disorder, to include arthritis, are not met. 38 U.S.C. §§ 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309(a). 6. The criteria for service connection for BPH are not met. 38 U.S.C. §§ 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from June 1976 to March 1978. On the June 2013 request for examination and on VA examination, VA indicated that the Veteran was seeking service connection for depression, to include as secondary to chronic otitis externa, bilateral hearing loss, tinnitus, and BPH. Therefore, the Board has modified the Veteran’s claim of entitlement to service connection for depression to include as secondary to chronic otitis externa, bilateral hearing loss, and tinnitus. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (stating that, when determining the scope of a claim, the Board must consider “the [Veteran’s] description of the claim; the symptoms the [Veteran] describes; and the information the [Veteran] submits or that the Secretary obtains in support of that claim”). On the June 2016 VA examination for hearing loss and ear conditions, the VA examiner offered an opinion addressing entitlement to service connection for tinnitus, to include as secondary to chronic otitis externa. Therefore, the Board has modified the Veteran’s claim of entitlement to service connection for tinnitus to include as secondary to service-connected chronic otitis externa. See id. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially 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). In addition, service connection for certain chronic diseases, including sensorineural hearing loss and arthritis, may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309(a); Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015). Although the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). 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. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 1. Whether new and material evidence has been submitted to reopen a claim for entitlement to service connection for bilateral hearing loss. The Veteran most recently filed a request to reopen his claim for entitlement to service connection for bilateral hearing loss in November 2012. At the time of the last final denial of the Veteran’s claim in February 1980, evidence of record included service treatment records (STRs) and VA treatment records. Evidence associated with the claims file since the previous February 1980 denial includes statements from the Veteran, VA treatment records, and VA examinations. Based on a review of this new evidence, the Board finds that the new and material criteria under 38 C.F.R. § 3.156(a) have been satisfied, and the claim for service connection for bilateral hearing loss is reopened. 2. Entitlement to service connection for bilateral hearing loss. For the purposes of applying the laws administered by VA, impaired hearing is considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, and 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of those 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. It has been established that 38 C.F.R. § 3.385 does not preclude service connection for a current hearing disability where hearing was within normal limits on audiometric testing at separation from service if there is sufficient evidence to demonstrate a medical relationship between the Veteran’s in-service exposure to loud noise and current disability. See Hensley v. Brown, 5 Vet. App. 155 (1993). The Board notes that the directives in Hensley are consistent with 38 C.F.R. § 3.303(d). The Veteran’s STRs document that he experienced a threshold shift from enlistment to separation from service. The Veteran’s military occupational specialty as a law enforcement specialist indicates that he had noise exposure. The Veteran’s June 1976 enlistment examination found puretone thresholds, in decibels, as: HERTZ 1000 2000 3000 4000 Avg RIGHT 0 0 --- 0 0 LEFT 0 0 --- 0 0 On the February 1978 separation examination, the audiological examination found puretone thresholds, in decibels, as: HERTZ 1000 2000 3000 4000 Avg RIGHT 10 10 15 15 13 LEFT 10 10 15 20 11 On the June 2013 VA examination, the Veteran stated that his voice sounds a little muffled or foggy. He stated that he turned the television up louder than normal. He stated that if someone speaks to him without his attention, the person must repeat themselves before he can hear them. The June 2013 VA audiological examination found puretone thresholds, in decibels, as: HERTZ 1000 2000 3000 4000 Avg RIGHT 5 5 15 20 11 LEFT 5 10 5 25 11 The average thresholds were 11 decibels in the right ear and 11 in the left ear. Speech audiometry revealed speech recognition ability of 98 percent in the right ear and 100 percent in the left ear. The June 2013 VA examiner found that the Veteran did not meet criteria for hearing loss according to VA regulations. The examiner opined that the Veteran’s hearing loss is less likely than not caused by service. The examiner reasoned that the Veteran had normal hearing bilaterally at entrance and separation from service. Based on the June 2013 findings, the Board finds that the Veteran does not have hearing loss for VA purposes, as there are no frequencies 40 decibels or greater, no three frequencies 26 decibels or greater, or a Maryland CNC test less than 94 percent. See 38 C.F.R. § 3.385. The Board notes that the Veteran’s STRs reveal that he had normal hearing during service for VA disability purposes. However, the Board notes that the audiometric data from the separation examination included increased puretone thresholds in the frequency range of 500 to 4,000 Hertz. In addition, the Board has carefully reviewed the Veteran’s statements of record. The Veteran stated that he was exposed to loud noise as a law enforcement officer. The Board finds that the Veteran, as a lay person, is competent to testify to having been exposed to loud noises during service and experiencing decreased hearing acuity. See Layno, 6 Vet. App. at 470. Moreover, there is no evidence to doubt his credibility. The Veteran’s statements regarding his noise exposure while in service are consistent with his MOS. The Veteran’s statements also reflect a continuity of symptomatology of hearing loss. Accordingly, the Board assigns great probative weight to the Veteran’s statements regarding the inception and persistence of bilateral hearing loss. 38 C.F.R. § 3.303(b). The Board further notes that although the June 2013 VA examiner had a negative opinion regarding etiology and military service, the medical provider reasoned that the Veteran had normal hearing sensitivity in both ears at the time of his separation examination. This rationale is legally insufficient. In Hensley v. Brown, the Court of Appeals for Veterans Claims held that 38 C.F.R. § 3.385 does not preclude service connection for a current hearing disability merely because hearing was within normal limits on audiometric testing at separation from service. Therefore, the Board finds that the June 2013 VA opinion is inadequate with respect to the question of nexus. However, upon review of the record, the Board finds that there is no competent evidence of current hearing loss in the Veteran’s bilateral ears. In the absence of proof of hearing loss, there can be no valid claim as to this issue. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Congress has specifically limited entitlement to service connection to cases where incidents have resulted in a disability. Brammer, 3 Vet. App. at 225. In the absence of any competent evidence of any current bilateral hearing loss, the Board must conclude the Veteran does not currently suffer from any such disability and must thus deny the Veteran’s claim as to that particular issue. See Degmetich v. Brown, 104 F.3d 1328, 1333 (1997) (holding that the existence of a current disability is the cornerstone of a claim for disability compensation). 3. Entitlement to service connection for a left knee disorder, to include arthritis. 4. Entitlement to service connection for a right knee disorder, to include arthritis. The Veteran asserts that he is entitled to service connection for a bilateral knee disorder. However as outlined below, the preponderance of the evidence demonstrates that the Veteran’s bilateral knee disorder did not manifest during, within the year following, or as a result of active service. As such, service connection cannot be established on a direct basis. The Veteran’s STRs are silent for complaints or treatment for a bilateral knee disorder. The Veteran’s February 1978 separation examination found the Veteran’s lower extremities and musculoskeletal system to be normal. Further, on the February 1978 report of medical history the Veteran indicated that he did not experience arthritis or “tricked” or locked knee. A March 2013 VA treatment record is the Veteran’s first report of bilateral knee pain. He reported that he did not experience any trauma to the knee. A May 2013 VA imaging report found that the Veteran’s symptoms were consistent with osteoarthritis. In August 2013 the VA medical provider found that the imaging showed mild degenerative joint disease (DJD). An August 2016 VA imaging report diagnosed the Veteran with osteoarthritis in the bilateral knee. Based on the foregoing, there is no evidence that the Veteran’s bilateral knee disorder, to include DJD and osteoarthritis, was manifested in service or to a compensable degree in the first year following his separation from service. Specifically, at separation from service, the Veteran’s musculoskeletal system was normal, and he made no musculoskeletal or knee complaints. Further, the first indication of a bilateral knee disorder was in 2013, 35 years after separation from service. Consequently, service connection for a bilateral knee disorder, to include arthritis, on the basis that such became manifest in service and persistent, or on a presumptive basis (as a chronic disease under 38 U.S.C. § 1112), is not warranted. Notably, the Veteran has not submitted competent evidence to show that he suffered from a bilateral knee disorder continuously since service. See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 288, 295-96 (1997). The Board acknowledges that the Veteran has not been afforded a VA examination for the bilateral knees, but finds no such opinion is required. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The Veteran was not treated for a bilateral knee disorder in service and there is no competent and credible evidence of persistent symptoms from separation from service to the ultimate diagnosis; nor is there evidence that the current knee disorder is related to service. As such, the Board finds that a VA examination was not required. Further, the Veteran’s own statements relating his bilateral knee disorder to service are not competent evidence, as he is a layperson and lacks the training to provide adequate opinion regarding medical etiology. Specifically, the Veteran lacks the training to opine whether a bilateral knee strain or arthritis, in the absence of credible evidence on continuity, as here, are related to service. See Jandreau v. Nicholson, 492 F. 3d (1372 (Fed. Cir. 2007) (Whether lay evidence is competent and sufficient in a particular case is a fact issue to be addressed by the Board rather than a legal issue to be addressed by the Court). Also, arthritis is a disease of the musculoskeletal system, and the record does not show that the Veteran has training or eduction in this medical field; therefore, lay evidence of its etiology is not competent nexus evidence as it is not capable of lay observation. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007); Layno v. Brown, 6 Vet. App. 465, 469-70. Thus, the Veteran is not competent or qualified, as a layperson, to render an opinion on medical causation. In light of the foregoing, the Board concludes that the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for a bilateral knee disorder, to include DJD and osteoarthritis. Accordingly, the claims must be denied. 5. Entitlement to service connection for BPH. The Veteran asserts that he is entitled to service connection for BPH. However as outlined below, the preponderance of the evidence of record demonstrates that the Veteran’s BPH did not manifest as a result of active service. As such, service connection cannot be established on a direct basis. The Veteran’s STRs indicate that on his February 1978 separation examination, the medical provider indicated that the Veteran had an abnormal genitourinary system and was provided a urology consultation. On the February 1978 report of medical history, the Veteran reported that he experienced frequent or painful urination. The medical provider on the separation examination noted that the Veteran’s painful urination was the result of a sexually transmitted disease. On the February 1978 urology consultation, the Veteran reported that he experienced occasional burning and discharge. The medical provider diagnosed the Veteran with nonspecific urethritis. On the March 1978 follow-up urology consultation, the medical provider indicated that the Veteran was no longer experiencing burning and discharge. On physical examination, the March 1978 medical provider observed that the Veteran’s external genitalia and prostate were “OK” and indicated there was no need for follow-up treatment. In a June 1982 VA treatment record, the Veteran was admitted to VA for treatment. He complained of urethral discharge and dysuria. The medical providers found that the Veteran experienced a bacterial infection and was treated with an antibiotic. At discharge from VA treatment, the Veteran’s infection was clear. In a September 2008 VA treatment record the Veteran first complained of problems with urination for the past month. The medical provider assessed that the Veteran had possible urinary tract infection and mild chronic prostatitis with prostate specific antigen. VA did not treat the Veteran for urology symptoms again until December 2011. In a November 2012 VA treatment record the medical provider assessed that the Veteran had urinary retention. However, the Veteran’s prostate evaluation was negative. A December 2012 medical provider assessed that that the Veteran’s ultrasound was suggestive of an enlarged prostate. In March 2013, the Veteran reported a worsening of prostate problems. On the June 2013 VA examination, the Veteran reported that he experienced symptoms in service and was treated one time after discharge from service with an antibiotic. The examiner indicated that the Veteran was diagnosed with BPH in 2012. The examiner opined that the Veteran’s recurrent urethritis, and one episode of prostatitis in STRs, would less likely than not cause the Veteran’s current BPH. The examiner stated that the BPH is more likely than not age related. Based on the foregoing, there is no evidence that the Veteran’s BPH was manifested in service or to a compensable degree in the first year following his separation from service. Specifically, at separation the Veteran’s urology consultation resulted in normal genitalia and prostate after treatment. Further, the treatment in 1982 was for a bacterial infection that was treated with antibiotics, and there were no further complaints or treatment for any genitourinary system disorders until 2008, 30 years after separation from service. Consequently, service connection for BPH on the basis that such became manifest in service and persistent is not warranted. Notably, the Veteran has not submitted competent evidence to show that he suffered from a genitourinary system disorder continuously since service. See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 288, 295-96 (1997). There is also no competent medical evidence that the Veteran’s BPH is otherwise related to service. The Veteran’s post-service treatment records are silent for any opinion relating this disorder to service. The only competent evidence in the record that addresses this question is the June 2013 VA medical opinion, which stated that the Veteran’s BPH is not related to service. As there is no other competent evidence to the contrary and the June 2013 VA medical opinion was based on a full review of the record as well as an interview and examination of the Veteran, the Board finds it persuasive. Further, the Veteran’s own statements relating his BPH are not competent evidence, as he is a layperson and lacks the training to provide adequate opinion regarding medical etiology. Specifically, the Veteran lacks the training to opine whether BPH is related to service. See Jandreau v. Nicholson, 492 F. 3d (1372 (Fed. Cir. 2007) (holding that whether lay evidence is competent and sufficient in a particular case is a fact issue to be addressed by the Board rather than a legal issue to be addressed by the Court). Also, BPH is a disease of the genitourinary system, and the record does not show that the Veteran has training or education in this medical field; therefore, lay evidence of its etiology is not competent nexus evidence as it is not capable of lay observation. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007); Layno v. Brown, 6 Vet. App. 465, 469-70. Thus, the Veteran is not competent or qualified, as a layperson, to render an opinion on medical causation. In light of the foregoing, the Board concludes that the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for BPH. Accordingly, the claim must be denied. REASONS FOR REMAND 1. Entitlement to an initial compensable rating for chronic otitis externa is remanded. In the June 2018 informal hearing presentation (IHP), the Veteran through his representative, asserted that his chronic otitis externa warrants a compensable rating. The Veteran last underwent a VA examination in June 2016. However, since that the time, the Veteran and his representative stated in the June 2018 IHP that his symptoms have worsened in the intervening years. As it has been over two years since the Veteran has been provided with VA examination concerning his claim for increased rating for chronic otitis externa and there is an assertion of worsening symptomatology, a remand is warranted to ensure that the record contains evidence of the current severity of the Veteran’s service-connected chronic otitis externa. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; Green v. Derwinski, 1 Vet. App. 121 (1991); Caffrey v. Brown, 6 Vet. App. 377 (1994). 2. Entitlement to service connection for tinnitus, to include as secondary to chronic otitis externa, is remanded. Remand is required to obtain an adequate medical opinion, or if necessary, a new VA examination. A medical opinion report is considered adequate “where it is based on consideration of the veteran’s prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board’s evaluation of the claimed disability will be a fully informed one.” Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Here, on the June 2016 VA examination for ear conditions, the examiner was unable to opine if the Veteran’s tinnitus was caused or aggravated by the Veteran’s service-connected chronic external otitis and serous otitis media. The examiner stated that he cannot speculate as this opinion was outside of his medical expertise. The examiner was unable to address whether the Veteran’s tinnitus was caused or aggravated by his service-connected chronic external otitis. Therefore, another medical opinion is warranted from an appropriate clinician that is able to provide this opinion. 3. Entitlement to service connection for depressive disorder, to include a sleep disorder and to include as secondary to chronic otitis externa and tinnitus, is remanded. Here, on the June 2013 VA examination, the examiner indicated that the Veteran was diagnosed with depression on an uncertain date. The examiner diagnosed the Veteran with hypochondriasis, depressive disorder not otherwise specified, and opioid dependence in early full remission. The examiner opined that the Veteran’s depression is less likely than not due to or the result of service. The Veteran reported developing depressive and anxious symptoms, which persist to this day, after separation from service due to his concerns about his health. The VA examiner did not address the Veteran’s claim of secondary service connection; therefore, a remand is required to obtain an addendum opinion, or a new VA examination if necessary, to address secondary service connection. 4. Entitlement to service connection for drug and alcohol abuse is remanded. Generally, service connection may not be awarded for alcohol or drug abuse. See 38 U.S.C. § 1131 (“no [VA] compensation shall be paid if the disability is the result of the veteran’s own willful misconduct or abuse of alcohol or drugs”); see also 38 U.S.C. § 105(a); VAOPGCPREC 7-99; VAOPGCPREC 2-98. Service connection for drug and alcohol abuse may only be established on a secondary basis where it is proximately due to or the result of a service-connected disease or injury. See 38 C.F.R. § 3.310(a). In Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001), the Federal Circuit held that a veteran could receive compensation for an alcohol or drug abuse disability acquired as secondary to, or as a symptom of, a veteran’s service-connected disability. Specifically, service connection for an alcohol or drug abuse disability is available only “where there is clear medical evidence establishing that alcohol or drug abuse is caused by a veteran’s primary service-connected disability, and where the alcohol or drug abuse disability is not due to willful wrongdoing.” See Allen, 237 F.3d at 1381. The Veteran seeks service connection for drug and alcohol abuse, to include as related to his claimed depressive disorder or sleep disorder. The Veteran’s claim for drug and alcohol abuse may only be considered on a secondary basis and not on a direct basis for entitlement. See Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001). Therefore, as the Veteran’s claim for depressive disorder is remanded for an addendum VA opinion, or a new VA examination if necessary, the examiner is to opine whether the Veteran’s drug and alcohol abuse is secondary to his depressive disorder or sleep disorder. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected chronic otitis externa. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to chronic otitis externa alone and discuss the effect of the Veteran’s chronic otitis externa on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 2. Obtain an addendum opinion, and if necessary additional VA examination, from an appropriate clinician to determine the nature and etiology of the Veteran’s tinnitus. The claims file and a copy of this remand should be made available to the examiner. The need for a physical examination is left to the examiner’s discretion. After reviewing the file, the examiner is asked to determine the nature and etiology of tinnitus. The examiner must opine on secondary service connection. Specifically, the examiner must answer the following questions: 1) Whether tinnitus is at least as likely as not proximately due to service-connected chronic otitis externa. 2) Whether tinnitus is at least as likely as not aggravated beyond its natural progression by service-connected chronic otitis externa. 3. Obtain an addendum opinion, and if necessary additional VA examination, from an appropriate clinician to determine the nature and etiology of a mental disorder, to include depressive disorder, sleep disorder, and drug and alcohol abuse. The examiner must opine whether any diagnosed mental disorder is at least as likely as not related to the Veteran’s service, including as related to health concerns in service. The examiner must consider the Veteran’s statements. The examiner must also opine on secondary service connection. Specifically, the examiner must answer the following questions: 1) Whether the depressive disorder or sleep disorder is at least as likely as not proximately due to service-connected disability, specifically chronic otitis externa, or to tinnitus. 2) Whether the depressive disorder or sleep disorder is at least as likely as not been aggravated beyond its natural progression by service-connected disability, specifically chronic otitis externa, or tinnitus. 3) Whether the drug and alcohol abuse is at least as likely as not proximately due to or the result of the Veteran’s depressive disorder or sleep disorder. CAROLINE B. FLEMING Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Thompson, Associate Counsel