Citation Nr: 21006306 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 17-16 914A DATE: February 3, 2021 ORDER Entitlement to service connection for bilateral hearing loss, to include as secondary to service-connected tinnitus, is granted. FINDING OF FACT The evidence of record is at least in equipoise that the Veteran’s bilateral hearing loss is aggravated by his service-connected tinnitus. CONCLUSION OF LAW The criteria for service connection for bilateral hearing loss have been met. 38 U.S.C. §§ 1101, 1110, 1131, 1112, 1113, 1116, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active military service from June 1966 to May 1970. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). By way of background, in December 2017 the Board adjudicated the issue of entitlement to an increased rating for service-connected PTSD and remanded the issues of entitlement to service connection for bilateral hearing loss and gastrointestinal disability for further evidentiary development. In November 2019, the Board granted the Veteran’s claim for entitlement to service connection for gastrointestinal disability and remanded the claim for entitlement to service connection for bilateral hearing loss. Service Connection Generally, to establish service connection 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.” Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be granted on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. The evidence must show: (1) that a current disability exists; and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448-49 (1995). Entitlement to service connection for bilateral hearing loss, to include as secondary to service-connected tinnitus, is granted. After a review of the record, the Board finds that the Veteran meets the standards for service connection for bilateral hearing loss as the preponderance of the evidence supports a finding that the Veteran’s bilateral hearing loss is aggravated by his service-connected tinnitus. At the outset, the Board notes that the Veteran has a current diagnosis of bilateral hearing loss that meets the criteria of 38 C.F.R. § 3.385. See April 2014 CAPRI. As such, the first element of service connection is met. The Board also concedes that the Veteran was exposed to some degree of noise during active service. The Veteran stated that his bilateral hearing loss manifested in service as a result of being “rocketed and mortared almost every night” in Vietnam. See May 2014 NOD. Further, the Veteran reported that as a driver of Armored Personnel Carrier he had a 50-caliber rifle next to his head and as such his ears were exposed to loud excessive noise from rifle shots, mortars, and rockets. See September 2017 VA 646 Statement of Accredited Representative in Appealed Case. In the alternative, the Veteran argued that his bilateral hearing loss was caused or aggravated by his service-connected tinnitus. See September 2019 Appellate Brief. The Board notes that the Veteran was afforded a VA examination in April 2014 with addendum opinions in January 2020 and May 2020. In the April 2014 examination, the examiner diagnosed the Veteran with bilateral hearing loss and opined that it is less likely as not that the Veteran’s bilateral hearing loss was caused by or a result of military noise exposure. The examiner explained that there was no permanent positive threshold shift greater than normal measurement variability at any frequency between 500 and 6000 Hertz for the bilateral ears. In fact, the enlistment and separation examination show normal bilateral hearing. Further, post military, the Veteran reported that he worked for a phone company as a repairman for four years, auto mechanic for six years, and heavy construction service manager in an office setting for 23 years. In November 2019, the Board remanded the issue on appeal as the April 2014 examiner did not address whether appropriate conversions from American Standards Association (ASA) to International Standards Organization-American National Standards Institute (ISO-ANSI) were made. Further, the examiner did not address whether it is at least as likely as not that the Veteran’s bilateral hearing loss was caused or aggravated by his service-connected tinnitus. Based on the November 2019 Board remand order, addendum opinions were obtained. In January 2020, an audiologist opined that the Veteran’s bilateral hearing loss is less likely as not caused by or a result of military service. See September 2020 CAPRI. The examiner explained that the April 1966 enlistment audiogram and March 1970 separation audiogram showed normal hearing bilaterally with no significant positive threshold with appropriate conversions from ASA to ISO. The audiologist also opined that the Veteran’s bilateral hearing loss is less likely as not caused by or aggravated by his service-connected tinnitus. The audiologist explained that tinnitus is a symptom associated with hearing loss not a cause of sensorineural hearing loss. In the May 2020 VA addendum opinion, the examiner noted that in service the Veteran was a communication systems current controller which was later changed to fixed station tech control. The noise probability designation is likely of low noise probability and no worse than a moderate noise probability. The April 1966 entrance examination, converted from ASA to ISO standards, indicated a mild low frequency hearing loss AU at 500 Hertz. Otherwise all thresholds were normal in the bilateral ears. The separation examination noted of normal hearing thresholds of the bilateral ears with a pure tone average of 0 decibel (dB). The examiner stated that there is no conversion needed for separation audiogram to ISO standards because the thresholds were already to ISO standards. As such, the examiner determined that there was no permanent hearing threshold shift or hearing loss at separation. Further, there was no evidence of acoustic trauma that caused a permanent hearing threshold shift. The examiner opined that the Veteran’s bilateral hearing loss is less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner explained that although noise exposure is conceded there is no evidence of acoustic trauma in service. There is no evidence of hearing loss during service and the Veteran did not endorse having hearing loss, hearing difficulty or tinnitus at time of separation. Hearing thresholds were normal for the bilateral ears at separation and there was no permanent hearing threshold shift which would be objective evidence of acoustic trauma. The examiner referenced the “Noise and Military Service – Implications for Hearing Loss and Tinnitus” from the Institutes of Medicine of the National Academy (2005) which stated that as the interval between a noise exposure and the onset of tinnitus lengthens, the possibility that tinnitus will be triggered by other factors increases. Furthermore, current knowledge of cochlear physiology does not provide sufficient scientific basis for the existence of delay-onset hearing loss nor tinnitus. Tinnitus was first reported by the Veteran 40+ years post separation after working in noise hazardous civilian occupations for at least 33 years: phone repairmen, auto mechanic, heavy equipment, and construction. Rubak et al (2008) reported that noise induced tinnitus is typically not present if the person has a normal audiogram. The Veteran had normal hearing at separation. Additionally, Mathur et al (July 2018) in an update on “Noise Induced Hearing Loss Clinical Presentation” indicated that once noise exposure is discontinued, noise induced hearing loss does not occur. The examiner concluded that the evidence is against a nexus and as such the Veteran’s bilateral hearing loss is less likely than not incurred in or caused by the claimed noise exposure during military service. The examiner also opined that the Veteran’s bilateral hearing loss is less likely than not proximately due to or the result of the Veteran’s service-connected tinnitus. The examiner explained that tinnitus is a symptom of hearing loss and cannot be attributed to causing hearing loss. ‘Tinnitus is the perception of noise or ringing in the ears.’ In fact, tinnitus is not a condition itself rather it is a symptom of an underlying condition, such as age-related hearing loss, ear injury or a circulatory system disorder. There is no evidence of acoustic trauma in service. There is no evidence of hearing loss during service and the Veteran did not report hearing loss, hearing difficulty or tinnitus at the time of separation. Hearing thresholds were normal for the bilateral ears at separation and there was no permanent hearing threshold shift which would be objective evidence of acoustic trauma. The examiner determined that the Veteran’s hearing loss occurred post separation and independent of noise exposure during military service as the Veteran worked in civilian occupations for at least 33 years that were noise hazardous and a contributor to his noise induced hearing loss. The Veteran’s post separation occupational noise exposure is the contributing factor to his current hearing loss of the bilateral ears. As such, the examiner opined that the Veteran’s hearing loss is less likely as not aggravated beyond its natural progression by service-connected tinnitus. In the May 2020 addendum opinion, the same examiner clarified that there is no medical literature to support tinnitus causing hearing loss or aggravating hearing loss. Although correlation exists between tinnitus and hearing loss, tinnitus causing, or aggravating hearing loss is not shown. Etiology of hearing loss can be caused by outer ear, middle or inner ear conditions. Tinnitus is a symptom of an underlying disease, not a disease process itself. The perception of sound may subjectively decrease hearing temporarily, however, there is no evidence to suggest any further connection. (Continued on the next page)   The Board finds that the evidence of record is at least in equipoise that the Veteran’s bilateral hearing loss is secondary to his service-connected tinnitus. Specifically, the May 2020 examiner conceded that the perception of sound may subjectively decrease hearing temporarily during a tinnitus episode. As a finding of aggravation does not require permanent worsening the Board finds that the Veteran’s tinnitus aggravates the Veteran’s bilateral hearing loss so that the Veteran may experience decreased hearing. Based on the foregoing, the Board grants the Veteran’s claim for entitlement to service connection for bilateral hearing loss secondary to his service-connected tinnitus. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Noh, 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.