Citation Nr: 21072684 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 20-27 837 DATE: December 6, 2021 ORDER Entitlement to service connection for bilateral adrenal adenomas is denied. Entitlement to service connection for a perforated tympanic membrane, to include as secondary to service-connected bilateral hearing loss, is denied. FINDINGS OF FACT 1. The Veteran's bilateral adrenal adenomas first manifested many years after service and are unrelated to any incident of service, including exposure herbicide agents therein. 2. The Veteran's perforated tympanic membrane of the left ear, status post tympanoplasty, is not attributable to his active-duty service, and is not proximately due to or aggravated by his service-connected bilateral hearing loss. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for bilateral adrenal adenomas have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.304, 3.307, 3.309, 3.311. 2. The criteria for entitlement to service connection for a perforated tympanic membrane, to include as secondary to service-connected bilateral hearing loss, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably on active duty from August 1958 to July 1962. These matters come before the Board of Veterans' Appeals (Board) on appeal from a November 2018 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA). By way of history, these claims were previously before the Board on multiple occasions, including in October 2020, March 2021, and August 2021. At these times, the Veteran's claims were remanded by the Board to the Agency of Original Jurisdiction (AOJ) for further evidentiary development prior to adjudication. The Board is satisfied that there has been substantial compliance with the August 2021 remand directives and will now proceed with appellate review. Service Connection Service connection may be granted for a disability resulting in a disease or injury that is incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 U.S.C. § 3.303. To establish service connection for the claimed disorder, the following criteria must be met: (1) evidence of a current disability; (2) evidence of an in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and current disability. See 38 C.F.R. § 3.303; see also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). In determining whether service connection is warranted for a disability, 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 claimant. 1. Entitlement to service connection for bilateral adrenal adenomas is denied. The Veteran asserts that his bilateral adrenal adenomas were related to service, to include as secondary to his exposure to herbicide agents during his nautical service in the offshore eligible waters of the Republic of Vietnam. Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). In addition to the above, service connection may also be granted for certain conditions due to Agent Orange exposure. VA laws and regulations provide that if a Veteran was exposed to Agent Orange during service, certain listed diseases are presumptively service connected. 38 U.S.C. § 1116 (a)(1); 38 C.F.R. § 3.309 (e). However, such diseases do not include adrenal adenomas. As such, the presumption for service connection under 38 C.F.R. § 3.309 (e) does not apply in this case. Notwithstanding the presumptive provisions, service connection for bilateral adrenal adenomas based on exposure to herbicides may also be established by showing that a disorder is, in fact, causally linked to exposure to herbicides during service. Combee v. Brown, 34 F. 3d. 1039 (Fed. Cir. 1994). Turning to the evidence of record, the Veteran was diagnosed with bilateral adrenal adenomas in April 2013. As such, the first element of service connection has been met. The Veteran's service treatment records (STRs) are silent for any complaints, treatment, or diagnosis of adrenal adenomas. Notably, in a May 2020 memorandum, VA conceded the Veteran's exposure to herbicide agents based on his nautical service in the offshore waters of the Republic of Vietnam during active duty. Regarding a causal link between the Veteran's bilateral adrenal adenomas and his active-duty service, to include exposure to herbicide agents therein, a VA medical opinion was obtained in October 2021. The October 2021 VA examiner opined that the Veteran's bilateral adrenal adenomas were less likely than not incurred in or caused by an in-service injury, event, or illness. The VA examiner reasoned upon diagnosis of the bilateral adrenal adenomas, they were considered "non-significant clinically and did not require further evaluation and/or treatment. These were not deemed biologically active and other than their presence, represent only a stable incidental finding. They are not related to Agent Orange exposure. Review the literature fails to return articles establishing Agent Orange as a cause of incidental bilateral adrenal adenomas. This review included Up to Date, a professional medical resource wherein one may access current professional treatises and studies. As noted above, these were considered incidental findings and do not cause any disability or symptoms, which is moot with respect to service connection. It is less likely than not that the Veteran's bilateral adrenal adenomas had their nexus in service, including herbicide/Agent Orange exposure. The average age at diagnosis is 57 and are found incidentally at autopsy in 2 to 3% of individuals." Upon review of the evidence summarized above, the Board concludes that while the Veteran has been diagnosed with bilateral adrenal adenomas, the preponderance of the evidence weighs against finding that they began during service or are otherwise etiologically related to an in-service injury, event, or disease, to include as secondary to exposure to herbicide agents. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. §§ 3.303(a), (d), 3.304, 3.307, 3.309. In this case, the Board gives great probative weight to the opinion provided by the October 2021 VA examiner, which indicated against a relationship between the Veteran's current bilateral adrenal adenomas and his active duty service, including as a result of exposure to herbicide agents, because it was based on a thorough and detailed review of all relevant evidence of record, he has the medical expertise to make such a determination, and in doing so, cited relevant research in support of his conclusion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board has considered the Veteran's lay opinion that his current bilateral adrenal adenomas are related to his military service, to include as a result of his conceded exposure to herbicide agents during service in the offshore waters of the Republic of Vietnam. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Board recognizes that the Veteran is competent to report observable symptoms related to tumors and adrenal adenomas; however, he does not claim or assert that he sought treatment in-service or shortly thereafter for symptoms related to these disorders. See Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Additionally, the Board finds the question of the exact diagnosis of his condition and the potential relationship between the Veteran's adenomas and service to be complex in nature. Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). Therefore, the Veteran cannot provide competent medical evidence establishing a connection between the two. Considering the above discussion, the Board concludes that the preponderance of the evidence is against the claim for service connection and there is no doubt to be otherwise resolved. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Therefore, the appeal is denied. 2. Entitlement to service connection for a perforated tympanic membrane, to include as secondary to service-connected bilateral hearing loss, is denied. The Veteran contends his perforated tympanic membrane is related to his active-duty service. Specifically, the Veteran asserts that his disability is a result of his mandatory duty in engine rooms of Navy ships, where he was exposed to loud noise and acoustic trauma. Alternatively, the Veteran asserts that his condition may be related to his service-connected bilateral hearing loss. The question for the Board is whether the Veteran's current disability began during service, is at least as likely as not related to an in-service injury or is proximately due to or aggravated by his service-connected bilateral hearing loss. The Board concludes that, while the Veteran has a current diagnosis of perforated tympanic membrane status post right tympanoplasty, and evidence shows that he had in-service noise exposure and acoustic trauma, the preponderance of the evidence is against finding that the Veteran's disability began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). The Veteran's perforated left tympanic membrane is not shown in service or for years after service. As such, the Board finds that the Veteran's perforated left tympanic membrane status post tympanoplasty is not attributable to his active-duty service. The Veteran's STRs do not contain any complaints related to his tympanic membrane, nor treatment for related conditions. Notably, on his July 1962 separation examination, the Veteran's ears were noted as normal. See July 1962 separation examination, report of medical examination. His post-service medical records include records from July 1965, which reflect a perforation of the Veteran's left ear and tympanic membrane following treatment for problems with his left ear in 1964 and 1965. Private medical records from August 1973 reflect the Veteran subsequently underwent a type I tympanoplasty on his left ear. Additionally, private medical records from a Dr. O. M. from May 1979 reflect that the Veteran struggled with chronic otitis media in the left ear. Dr. O. M. recommended an additional tympanoplasty of the left ear to close the defect present in the tympanic membrane. The Veteran underwent multiple VA examinations for his tympanic membrane condition. Most relevant to the question before the Board, an addendum VA medical opinion was obtained in October 2021 addressing the etiology of the Veteran's perforated tympanic membrane. The October 2021 VA examiner opined that "it is less likely than not that the Veteran's perforated tympanic membrane is due to or was incurred in service, including [from the] claimed acoustic trauma. It is more likely than not that the perforated tympanic membrane occurred in or around 1973." The October 2021 VA examiner reasoned that "there is no evidence of a ruptured tympanic membrane in service. The separation exam is negative for perforated tympanic membrane. These exams are notably thorough and include a history, physical, and usually a Veteran-answered [report of medical history] (not located). The Veteran's physical exam was negative and there are no records of complaints suggestive of a ruptured tympanic membrane. It is highly unlikely a significant tympanic membrane condition would've gone unnoted or unreported. Furthermore, acoustic trauma is unlikely to cause perforation and if such, would likely have led to evaluation and treatment/follow-up as the forces involved would be substantial (jet blast or bomb blast). Regardless, there is no evidence of a ruptured tympanic membrane until 1973, per the Veteran's own statements. Further, the examiner stated that "hearing loss does not cause a perforated tympanic membrane. This also applies to aggravation. Hearing loss would have no impact on the tympanic membrane itself. Therefore, it cannot cause or aggravate the Veteran's ruptured tympanic membrane. The Veteran's tympanic membranes were not visible at the time of the disability benefits questionnaire (DBQ) due to cerumen. It is not clear if the perforation is still present or has healed. In summary, it is less likely than not that the Veteran's ruptured tympanic membrane is due to or was incurred in service. It almost certainly occurred in 1973 or later, per the Veteran's own words. [A perforated tympanic membrane] is not caused by hearing loss. It is not aggravated by hearing loss. The audio DBQ dated November 2018 noted bilateral mixed hearing loss. Unfortunately, there is no exam of the tympanic membranes accompanying the audiology report. There is no notation of a ruptured tympanic membrane in the history or evidence in the audiology findings and an audiologist would be required to render an opinion of any impact of the Veteran's ruptured tympanic membrane on hearing." The Board finds that the evidence of record does not support a finding of service connection for status post-left perforated tympanic membrane. The medical evidence of record does not relate the Veteran's perforated tympanic membrane to service as summarized above, the October 2021 VA examiner found that the Veteran's perforated tympanic membrane likely occurred following his separation from service and further, is not related to his service-connected bilateral hearing loss. The Board finds the October 2021 VA opinion persuasive and probative as it was based on a thorough and detailed review of all relevant evidence of record, he has the medical expertise to make such a determination. The Veteran did not report a perforated tympanic membrane during service. However, to the extent he may be interpreted as arguing such due to simply filing his claim, the Board notes that the evidence of record does not demonstrate that the Veteran has the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Therefore, the Veteran is not competent to provide an opinion on the etiology of his perforated tympanic membrane. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007). (Continued on the next page) In the absence of any persuasive and probative evidence that the Veteran's perforated tympanic membrane is etiologically related to active service or is proximately due to or aggravated by his bilateral hearing loss, service connection is not warranted, and the claim must be denied. L. ANDERSEN Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. M. Lowman, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.