Citation Nr: 1827286 Decision Date: 05/01/18 Archive Date: 05/14/18 DOCKET NO. 09-23 699 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Salt Lake City, Utah THE ISSUES 1. Entitlement to service connection for thyroid cancer, and residuals of thyroid cancer, to include as secondary to service-connected gastrointestinal stromal tumor removal. 2. Entitlement to service connection for residuals of left wrist fracture, to include as secondary to service-connected gastrointestinal stromal tumor removal. 3. Entitlement to service connection for bilateral hearing loss, to include as secondary to service-connected gastrointestinal stromal tumor removal. 4. Entitlement to service connection for tinnitus, to include as secondary to service-connected gastrointestinal stromal tumor removal. 5. Entitlement to service connection for sleep apnea, to include as secondary to service-connected gastrointestinal stromal tumor removal. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD B. Riordan, Associate Counsel INTRODUCTION The Veteran had active service from May 1987 to December 1987, June 2003, December 2003, January 2004 through April 2005, June 2006, and November 2007. This appeal to the Board of Veterans' Appeals (Board) is from a January 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah. In November 2012 and September 2015, the Veteran's claims were remanded to the agency of original jurisdiction (AOJ) for additional development. Specifically, the Board directed that the AOJ to make all reasonable efforts to obtain the Veteran's dates of active duty service. In addition, the Board directed the AOJ to obtain an addendum medical opinion concerning if the Veteran's claimed disabilities were related to service, and if the Veteran's claimed disabilities were caused or aggravated by his service-connected gastrointestinal stromal tumor (GIST) removal. The Veteran's periods of active service and addendum medical opinion have been obtained and associated with the file. His periods of ACDUTRA and INACDUTRA were not able to be verified nor were any additional service treatment records (STRs) obtained. Numerous negative replies are documented and the Veteran has been notified of this. The Board finds there has been substantial compliance with the prior remand directives, and adjudication of the Veteran's claim may proceed. See Stegall v. West, 11 Vet. App. 268, 271 (1998). FINDINGS OF FACT 1. The Veteran's thyroid disability, and residuals of a thyroid disability, were not manifest in service; any current thyroid disability, and residuals of a thyroid disability, are not otherwise etiologically related to such service, or caused or aggravated by the Veteran's service-connected gastrointestinal stromal tumor removal. Alternatively, thyroid cancer clearly and unmistakably existed prior to active service from January 2004 to April 2005 and was clearly and unmistakably not aggravated by service. 2. The Veteran's residuals of left wrist fracture were not manifest in service; any current residuals of left wrist fracture are not otherwise etiologically related to such service, or caused or aggravated by the Veteran's service-connected gastrointestinal stromal tumor removal. Alternatively, the left wrist was clearly and unmistakably fractured prior to active service in June 2006 and was clearly and unmistakably not aggravated by service. 3. The Veteran's right ear hearing disability was not manifest in service; any current right ear hearing disability is not otherwise etiologically related to such service, or caused or aggravated by the Veteran's service-connected gastrointestinal stromal tumor removal. Left ear hearing loss clearly and unmistakably existed prior to active service from January 2004 through April 2005 and was clearly and unmistakably not aggravated by service. 4. The Veteran's tinnitus is related to service. 5. The Veteran's obstructive sleep apnea was not manifest in service; any current obstructive sleep apnea is not otherwise etiologically related to such service, or caused or aggravated by the Veteran's service-connected gastrointestinal stromal tumor removal. Alternatively, sleep apnea clearly and unmistakably existed prior to active service in November 2007 and was clearly and unmistakably not aggravated by service. CONCLUSIONS OF LAW 1. The criteria for service connection for a thyroid disability, and residuals of a thyroid disability, have not been met. 38 U.S.C. §§ 1110, 1111, 1131, 5107 (2012); 38 C.F.R. § 3.303, 3.310 (2017). 2. The criteria for service connection for residuals of a left wrist fracture have not been met. 38 U.S.C. §§ 1110, 1111, 1131, 5107 (2012); 38 C.F.R. § 3.303, 3.310 (2017). 3. The criteria for service connection for a bilateral hearing disability have not been met. 38 U.S.C. §§ 1110, 1111, 1131, 5107 (2012); 38 C.F.R. § 3.303, 3.310 (2017). 4. The criteria for service connection for tinnitus have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. § 3.303, 3.310 (2017). 5. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 1110, 1111, 1131, 5107 (2012); 38 C.F.R. § 3.303, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Neither the Veteran nor his representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Board decisions must be based on the entire record, with consideration of all the evidence. 38 U.S.C. § 7104. The law requires only that the Board address its reasons for rejecting evidence favorable to the veteran. Timberlake v. Gober, 14 Vet. App. 122 (2000). The Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). The third step of this inquiry requires the Board to weigh the probative value of the evidence in light of the entirety of the record. While the Veteran is competent to report (1) symptoms observable to a layperson, (2) a diagnosis that is later confirmed by clinical findings; or (3) a contemporary diagnosis, he is not competent to independently render a medical diagnosis or opine as to the specific etiology of a condition. See Davidson v. Shinseki, 581 F.3d 1313 (2009). Because there is no universal rule as to competence, the Board must determine on a case-by-case basis whether a particular condition is the type of condition that is within the competence of a lay person to provide an opinion as to etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24 Vet. App. 428 (2011). The Court has also held that contemporaneous records can be more probative than history as reported by a Veteran. See Curry v. Brown, 7 Vet. App. 59, 68 (1994). VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the veteran. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. In order to prevail on the issue of service connection there must be competent evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Where a veteran asserts entitlement to a chronic disease but there is insufficient evidence of a diagnosis in service, service connection may be established under 38 C.F.R. § 3.303(b) by demonstrating a continuity of symptomatology since service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). When a chronic disease manifests to a degree of 10 percent or more within 1 year from the date of separation from service, that disease is presumptively service-connected. 38 C.F.R. §§ 3.303(b), 3.307(a)(3). The Veteran's claimed sensorineural hearing loss is a chronic diseases as defined by 38 C.F.R. § 3.309(a). When a disease is first diagnosed after service, service connection is warranted for that condition if the competent evidence shows it was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a) (2017). Secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service-connected disability. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310 (b) (2017); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). Service Connection for Thyroid Cancer and Residuals of Thyroid Cancer The Veteran has claimed entitlement to service connection for thyroid cancer and residuals of thyroid cancer. The Board acknowledges the Veteran had thyroid cancer in 2000 and has current residuals as he takes medication. However, the probative evidence of record does not establish that the Veteran's thyroid disabilities, or residuals of those disabilities, are related to his active service, or were caused or aggravated by his service-connected GIST. The Veteran completed a VA examination regarding the etiology of his thyroid disability, and residuals of a thyroid disability, in January 2013. An addendum medical opinion was also provided in June 2016. The January 2013 examination and subsequent June 2016 medical opinion confirm a diagnosis of hypothyroidism and malignant neoplasm of the thyroid. The January 2013 examination noted that the Veteran's thyroid cancer was diagnosed in 2000, between the Veteran's periods of active service. While not dispositive of the issue, the Board may consider in its assessment of service connection the passage of a lengthy period of time wherein the Veteran has not complained of the malady at issue. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The January 2013 examiner also noted that the residuals of the Veteran's thyroid disabilities (chronic sleepiness, fatigue, irritability) were nonspecific in nature and could be the result of numerous medical conditions. In addition, the January 2013 VA examiner noted: There is no evidence to suggest that any 'residuals' from the thyroid cancer (diagnosed in 2000 after the first and prior to the second period of active service) were aggravated beyond their natural progression by the Veteran's military service. Further addressing the etiology of the Veteran's thyroid disability, and residuals of a thyroid disability, the June 2016 addendum opinion states the following: [The Veteran's] thyroid gland is absent and he has responded well to ongoing replacement therapy with Levoxyl and Cytomel medications which he will likely continue to require for the foreseeable future. Last assessment in 2012 showed no recurrence of cancer. Residual appears to be limited to ongoing thyroid hormone replacement therapy is documented on 1/16/13 which would be expected to continue. His metastatic papillary thyroid cancer was diagnosed in 2000 and the [service treatment records] contain no information to suggest any service-related exposure that would have predisposed the [V]eteran to this condition. [The Veteran] was a helicopter mechanic. It is most probable this condition evolved while not on active duty. No evidence was found to suggest an aggravation of this condition during time in service. The June 2016 VA examiner also opined that the Veteran's thyroid condition and residuals were not caused or aggravated by the Veteran's service-connected GIST removal, stating: The thyroid condition existed 4 years prior to the GIST removal. The [V]eteran's thyroid condition...has been relatively stable from 2000 forward, per review of the medical record, and does not appear to have been influenced in any way by the GIST removal. The [V]eteran's thyroid condition appears to have remained unchanged, treated with replacement therapy as it was prior to the [V]eteran's 2004 through 2005 time in service. The Board acknowledges the Veteran's contention that his thyroid disabilities, and their residuals, are related to his period of active service, and/or was caused or aggravated by his period of active service. Because there is no universal rule as to competence on this issue, the Board must determine on a case-by-case basis whether a particular condition is the type of condition that is within the competence of a lay person to provide an opinion as to etiology and/or aggravation. See Jandreau, 492 F.3d at 1376 -77; see also Kahana, 24 Vet. App. 428. Lay persons are competent to provide opinions on some medical issues. Id. at 435. Determining the etiology and/or aggravation of the Veteran's diagnosed thyroid disabilities, or their residuals, requires medical inquiry into internal biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the Veteran in this case, who has not been shown by the evidence of record to have medical training or skills. As a result, the probative value of his lay assertions is low. The Veteran's private medical records note treatment for thyroid disabilities, but do not establish that the Veteran's thyroid disabilities, or their residuals, are related to his active service. The private medical records also do not establish that the Veteran's thyroid disabilities, or their residuals, were caused or aggravated by the Veteran's service-connected GIST removal. The Board finds that there is no competent evidence or opinion of record to support the Veteran's assertion that his thyroid disabilities, or their residuals, are etiologically related to his active service, or were caused or aggravated by his service-connected GIST removal. Further, that the Board acknowledges that the probative evidence of record does not contain the Veteran's report of medical history or report of medical examination upon entrance to active duty in January 2004, June 2006, or November 2007. Where an entrance examination is lost or missing, the presumption of soundness attaches. See Doran v. Brown, 6 Vet. App. 283, 286 (1994). As such, the presumption of soundness attaches with regard to whether the Veteran had thyroid cancer, and residuals of thyroid cancer. Thus, the burden is on VA to show by clear and unmistakable evidence that the disability both pre-existed service and was not aggravated during service. Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). "When no preexisting condition is noted upon entry into service, the veteran is presumed to have been sound upon entry. The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the veteran's disability was both preexisting and not aggravated by service." Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). The Veteran's thyroid cancer and its residuals did not manifest during the Veteran's active service from May 1987 to December 1987. The probative evidence of record indicates the residuals of thyroid cancer did manifest during service in June 2003, December 2003, January 2004 to April 2005, June 2006, and November 2007, as the Veteran was taking medication for his thyroids cancer. However, as noted in the January 2013 examination and June 2016 addendum opinion, the Veteran's thyroid cancer, and residuals of thyroid cancer, were diagnosed in 2000 and existed prior to this period of active service. Moreover, the January 2013 examination and June 2016 addendum opinion note that the Veteran's thyroid cancer, and its residuals, have been stable and neither the cancer nor its residuals have been aggravated by the Veteran's active service. The Board finds that there is clear and unmistakable evidence that the Veteran's thyroid cancer and its residuals existed prior to service. Furthermore, the January 2013 and June 2016 opinions establish that it was clearly and unmistakably not aggravated by service. Accordingly, the presumption of soundness does not attach to the Veteran concerning his thyroid cancer or residuals of thyroid cancer. See Wagner, 370 F.3d at 1096. In light of the above discussed evidence, the Board concludes that the preponderance of the evidence is against the claim for service connection for the Veteran's thyroid disability and residuals of a thyroid disability. The benefit of the doubt rule therefore does not apply. Service Connection for Residuals of a Left Wrist Fracture The Veteran claims entitlement to service connection for residuals of a left wrist fracture. The Board acknowledges the Veteran has residuals of a left wrist injury. However, the probative evidence of record does not establish that the residuals of the Veteran's left wrist injury are related to his active service, or were caused or aggravated by his service-connected GIST. The Veteran completed a VA examination regarding the etiology of the residuals of his left wrist injury in January 2013. An addendum medical opinion was also provided in June 2016. The January 2013 examination confirms the Veteran suffered a left wrist fracture in May 2005. At examination the Veteran reported that residuals of the left wrist fracture include pain in the left hand and fingers, and weakness in the left wrist. Physical examination noted decreased range of motion in the Veteran's left wrist. The January 2013 VA examiner noted the Veteran's broken wrist was caused by falling from a mountain bicycle a month after leaving active service in April 2005. The Veteran's active service records confirm that his period of active service ended in April 2005. The Veteran's next period of active service began in June 2006. In turn, the examiner opined that the Veteran's residuals of a left wrist fracture were not directly related to service, and was not caused or aggravated by his service-connected GIST removal. The June 2016 VA addendum opinion further reasoned that the Veteran's residuals of a left wrist fracture were not directly related to service, stating: [The Veteran's] left wrist is weak, painful and has decreased range of motion per 1/16/13 examination... [The Veteran's] left wrist fracture appears to have been caused by a traumatic event that occurred during a period when not on active duty and the medical records provided do not suggest this was predisposed by any service-connected or related condition nor do they suggest aggravation of this condition while on active duty. The June 2016 VA examiner also opined that the Veteran's residuals of a left wrist fracture were not caused of aggravated by the Veteran's service-connected GIST removal. The examiner explained: The wrist fracture was due to a traumatic event that occurred after full recovery from the GIST removal, falling from a mountain bike, and had nothing to do with the GIST removal... the [V]eteran's wrist fracture did not occur until after the [V]eteran had essentially fully healed from his GIST removal. There is no rational mechanism of injury or of aggravation that would explain a causal relationship between the [V]eteran's GIST removal, his later wrist fracture, and the residuals that wrist fracture. The Board acknowledges the Veteran's contention that his residuals of a left wrist fracture are related to his period of active service, and/or were caused or aggravated by his service-connected GIST removal. As noted above, lay persons are competent to provide opinions on some medical issues. See Kahana, 24 Vet. App. at 435. However, determining the etiology and/or aggravation of the Veteran's residuals of a left wrist fracture requires medical inquiry into internal biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the Veteran in this case, who has not been shown by the evidence of record to have medical training or skills. As a result, the probative value of his lay assertions is low. In addition, there is no competent evidence or opinion of record to support the Veteran's assertion that his residuals of a left wrist fracture are etiologically related to his active service, and/or were caused or aggravated by his service-connected GIST removal. Further, as discussed above, the probative evidence of record does not contain the Veteran's report of medical history or report of medical examination upon entrance to active duty in June 2003, December 2003, January 2004, June 2006, or November 2007. Accordingly, the presumption of soundness attaches with regard to whether the Veteran had residuals of a broken wrist. Thus, the burden is on VA to show by clear and unmistakable evidence that the disability both pre-existed service and was not aggravated during service. As noted in the January 2013 examination and June 2016 addendum opinion, the Veteran's broken wrist was caused by a biking accident in May 2005, one month after leaving a period of active service. Moreover, the January 2013 examiner noted that the Veteran's medical treatment records and examination did not indicate that the Veteran's residuals of a broken wrist increased in severity during service. The Board finds that there is clear and unmistakable evidence that the Veteran's residuals of a broken wrist existed prior to active service in June 2006 and November 2007, and were not aggravated by service. Accordingly, the presumption of soundness is rebutted and does not attach to the Veteran concerning his residuals of a broken wrist. See Wagner, 370 F.3d at 1096. In light of the above discussed evidence, The Board concludes that the preponderance of the evidence is against the claim for service connection for the Veteran's residuals of a left wrist fracture. The benefit of the doubt rule therefore does not apply. Service Connection for Bilateral Hearing Loss For VA purposes, impaired hearing will be considered a disability when the auditory threshold for any of the frequencies of 500, 1000, 2000, 3000 and 4000 Hertz is 40 decibels or greater; the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2017). The Veteran's current level of hearing loss meets these criteria. However, the probative evidence of record does not establish that the Veteran's bilateral hearing loss is related to his active service, or was caused or aggravated by his service-connected GIST. Review of the Veteran's service treatment records establishes the Veteran's first diagnosis of left ear hearing loss was not until December 2001. The Veteran was not diagnosed with right ear hearing loss until December 2012, more than five years after his completion of his final period of active duty. As the Veteran's sensorineural hearing loss is listed as a chronic disease (organic disease of the nervous system) under 38 C.F.R. § 3.309(a), the provisions of 38 C.F.R. § 3.303(b) pertaining to continuity of symptomatology apply in this case. Nothing in the record indicates the Veteran was diagnosed with sensorineural hearing loss while in service or within 1 year of the date of separation from service, therefore the presumption of service connection for chronic diseases does not apply. 38 C.F.R. § 3.307(a)(3), 3.309(b). As will be discussed further below, the Veteran's left ear hearing loss met the criteria set forth in 38 C.F.R. § 3.385 prior to a period of active duty and therefore a separate analysis must be conducted regarding the presumption of soundness. The Veteran completed a VA examination regarding the etiology of his bilateral hearing loss in December 2012. An addendum medical opinion was also provided in June 2016. . Regarding the Veteran's hearing loss, the December 2012 examiner stated: The [V]eteran did not have a hearing loss which would be considered disabling according to VA standards in the right ear through at least April 2005. Two exams from December 2001 show differing results in the left ear. The [Veteran's service treatment records] indicate that there was not a significant change in hearing in either ear during the Veteran's active duty from January 2004 to April 2005...Given the lack of change in hearing during the [V]eteran's period of active duty, it is less likely as not that the Veteran's hearing loss was caused by or a result of his active duty military service. The June 2016 addendum opinion further detailed the etiology of the Veteran's hearing condition: The [V]eteran's bilateral hearing loss neither appears to have been caused by nor aggravated by time in service. In addition to military noise exposure, the [V]eteran had significant civilian, employment, and recreational noise exposures, not always well protected. There was no evidence of significant progression of his hearing loss between January 2004 and April 2005. The significant progression of his hearing loss is documented in 2012 and does not appear to be related to past time in service. The June 2016 VA examiner also reported the following concerning the Veteran's service-connected GIST removal causing or aggravating the Veteran's hearing loss: The hearing loss was not significantly changed from 1/7/04 before the GIST removal through 4/14/05, 5 months after the GIST removal...Review of the medical records strongly suggests the [Veteran] was fully recovered from his GIST removal several months prior to 4/14/05 and there is no known mechanism whereby his continued hearing loss would be associated with that past procedure. The Board acknowledges the Veteran's contention that his hearing loss is related to his period of active service, and/or was caused or aggravated by his service-connected GIST removal. As noted above, lay persons are competent to provide opinions on some medical issues. See Kahana, 24 Vet. App. at 435. However, determining the etiology and/or aggravation of the Veteran's hearing loss requires medical inquiry into internal biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the Veteran in this case, who has not been shown by the evidence of record to have medical training or skills. As a result, the probative value of his lay assertions is low. In addition, there is no competent evidence or opinion of record to support the Veteran's assertion that his hearing loss is etiologically related to his active service, and/or was caused or aggravated by his service-connected GIST removal. Further, the probative evidence of record does not contain the Veteran's report of medical history or report of medical examination upon entrance to active duty in January 2004, June 2006, or November 2007. Accordingly, the presumption of soundness attaches with regard to whether the Veteran had hearing loss. The presumption of soundness is not called into question with regard to the Veteran's right ear hearing loss. Furthermore, it did not manifest in service. For the reasons discussed above, the preponderance of the evidence is against service connection for right ear hearing loss. With regard to the Veteran's left ear hearing loss, the medical record shows that in December 2001, an audiogram noted that the Veteran's pure tone thresholds were 40 decibels at 3000 Hertz and 60 decibels at 4000 Hertz. This was prior to the Veteran's periods of active service in June 2003, December 2003, January 2004 to April 2005, June 2006, and November 2007. As the Veteran's left ear hearing loss met the criteria to be considered a disability under 38 C.F.R. § 3.385 prior to periods of active service, there is clear and unmistakable evidence that it existed prior to periods of service. Though the Veteran did manifest symptoms of left ear hearing loss during these periods of active service, the December 2012 VA examination and June 2016 addendum opinion note that there was no significant change in left ear hearing loss until 2012, and that hearing loss appears to be unrelated to service. The June 2016 VA examiner explained that the Veteran's hearing loss worsened in both ears after service was completed. The examiner also stated that the Veteran' had significant post-service occupational and recreational noise exposure and did not always have hearing protection. This shows that his hearing loss in his left ear was clearly and unmistakably not aggravated by service. Based on the probative evidence of record, the Board finds that the Veteran's left ear hearing loss clearly and unmistakably existed prior to service and was clearly and unmistakably not aggravated during service. Accordingly, the presumption of soundness is rebutted and does not attach to the Veteran concerning his left ear hearing loss. See Wagner, 370 F.3d at 1096. The claim for service connection for left ear hearing loss is therefore denied. In light of the above discussed evidence, the Board concludes that the preponderance of the evidence is against the claim for service connection for hearing loss in either ear. Service Connection for Tinnitus The Veteran has claimed entitlement to service connection for tinnitus. The Veteran's military records indicate the Veteran's occupational specialty was aircraft structural repair. The Board finds the Veteran's occupational specialty most likely resulted in high levels of noise exposure. The Veteran is competent to identify tinnitus, such as ringing in the ears, as such condition is readily observable by laypersons and does not require medical expertise to establish its existence. Charles v. Principi, 16 Vet. App. 370, 374 (2002). His report of ringing in his ears during service is not inconsistent with the circumstances of his MOS, and the Board finds his report to be competent and credible. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.159(a)(2). Unlike the Veteran's hearing loss claim where there are objective tests showing normal hearing, there are no similar reports expressly showing no tinnitus. Considering all lay and medical evidence of record, the Board resolves reasonable doubt in the Veteran's favor and finds that he currently has tinnitus as a result of noise exposure during service. See 38 U.S.C. § 510(b); 38 C.F.R. § 3.102. Therefore, service connection for tinnitus is warranted. Service Connection for Sleep Apnea The Veteran claims entitlement to service connection for obstructive sleep apnea. The Board acknowledges the Veteran has a current diagnosis of sleep apnea. However, the probative evidence of record does not establish that the Veteran's current sleep apnea is related to his period of active service, or was caused or aggravated by his service-connected GIST removal. Review of the Veteran's medical records indicate he was diagnosed with sleep apnea in October 2007, more than a year after the Veteran completed active service in June 2006, and one month prior to the Veteran's return to active service in November 2007. A January 2013 VA sleep apnea examination confirmed the Veteran's current diagnosis of sleep apnea. The January 2013 examiner noted that the Veteran's service treatment records did not include complaints of or treatment for sleep apnea, and noted that the Veteran's sleep apnea began did not begin during a period of active service. In turn, the VA examiner opined that the Veteran's current sleep apnea was not related to his period of active service. The January 2013 examiner also noted that the Veteran's sleep apnea was less likely than not caused or aggravated by the Veteran's service-connected GIST removal. A June 2016 VA addendum opinion further discussed the etiology of the Veteran's sleep apnea. The June 2016 VA addendum opinion stated: The [V]eteran's sleep apnea appears to be unrelated to his time in service... Review of medical literature supports a very strong relationship between obstructive sleep apnea and obesity. The [V]eteran weighed 290 pounds and had a BMI of 37.1 in 2007, when he was diagnosed with mild obstructive sleep apnea. Review of medical records suggests ongoing morbid obesity. The June 2016 VA addendum medical opinion also denied that the Veteran's sleep apnea was caused or aggravated by his service-connected GIST removal, stating: The sleep apnea did not appear to have been present in 2004 during the period of GIST removal. The [V]eteran did very well in healing from the GIST removal and follow up CT exam thereafter was essentially normal. All indications from the medical records following the procedure by the treating provider support a full recovery on or about January 2005. As there appear to have been no significant complications or residuals from the GIST removal, there appears to be no basis to support the supposition that the GIST removal lead to or aggravated any of the [Veteran's] claimed conditions. The Board acknowledges the Veteran's contention that his sleep apnea is related to his period of active service, and/or was caused or aggravated by his service-connected GIST removal. As noted above, lay persons are competent to provide opinions on some medical issues. See Kahana, 24 Vet. App. at 435. However, determining the etiology and/or aggravation of the Veteran's sleep apnea requires medical inquiry into internal biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the Veteran in this case, who has not been shown by the evidence of record to have medical training or skills. As a result, the probative value of his lay assertions is low. In addition, there is no competent evidence or opinion of record to support the Veteran's assertion that his sleep apnea is etiologically related to his active service, and/or was caused or aggravated by his service-connected GIST removal. Further, the probative evidence of record does not contain the Veteran's report of medical history or report of medical examination upon entrance to active duty in January 2004, June 2006, or November 2007. Accordingly, the presumption of soundness attaches during any of these periods of active duty service in which the Veteran's sleep apnea manifest. When the presumption of soundness attaches, the burden is on VA to rebut the presumption by clear and unmistakable evidence that the disability both pre-existed service and was not aggravated during service. At present, the Veteran's sleep apnea did not manifest during his period of active service from May 1987 to December 1987. The medical record establishes that the Veteran's sleep apnea was clearly and unmistakably diagnosed in October 2007, prior to the Veteran's periods of active service in November 2007. Though the Veteran did manifest symptoms of sleep apnea during this period of active service, the January 2013 VA examination and June 2016 addendum opinion note that the sleep apnea was not aggravated by service, and the probative evidence of record does not indicate that the Veteran's sleep apnea increased in severity during this period. The June 2016 examiner explained that in 2007 the Veteran weighed 207 pounds and that obesity was a likely cause of sleep apnea. There is clear and unmistakable evidence that sleep apnea was not aggravated by service, as the examiners noted no increase in severity in service. Accordingly, the presumption of soundness is rebutted and does not attach to the Veteran's sleep apnea. See Wagner, 370 F.3d at 1096. In light of the above discussed evidence, The Board concludes that the preponderance of the evidence is against the claim for service connection for sleep apnea. The benefit of the doubt rule therefore does not apply. ORDER Entitlement to service connection for residuals of thyroid cancer, to include as secondary to service-connected GIST is denied. Entitlement to service connection for residuals of left wrist fracture, to include as secondary to service-connected GIST is denied. Entitlement to service connection for bilateral hearing loss, to include as secondary to service-connected GIST is denied. Entitlement to service connection for tinnitus is granted. Entitlement to service connection for sleep apnea, to include as secondary to service-connected GIST is denied. ____________________________________________ D. Martz Ames Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs