Citation Nr: 21012021 Decision Date: 03/03/21 Archive Date: 03/03/21 DOCKET NO. 18-45 048 DATE: March 3, 2021 ORDER Entitlement to service connection for right ear hearing loss is denied. FINDINGS OF FACT 1. In-service exposure to acoustic trauma has been conceded. 2. The Veteran has a current diagnosis of right ear conductive hearing loss that meets the disability standard set forth in 38 C.F.R. § 3.385. 3. The preponderance of the evidence is against a finding that the Veteran’s right ear hearing loss, to include conductive hearing loss, began during service or is otherwise related to an in-service injury, event, or disease. CONCLUSION OF LAW The criteria for service connection for right ear hearing loss are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty in the United States Navy from January 2012 to January 2016. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2017 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In October 2018 and July 2020, the Board remanded the claim for further development. There has been substantial compliance with the Board’s remand directives and the claim is ripe for adjudication. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Entitlement to service connection for right ear hearing loss The Veteran asserts that her right ear hearing loss is related to acoustic trauma sustained as a result of noise exposure on active duty, or alternatively to her non-service-connected otitis media. See VA Form 9, received August 20, 2018. She denies post-separation noise exposure. For the following reasons, the Board finds that service connection for right ear hearing loss is not warranted. Direct service connection may be granted for a hearing loss disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: (1) the existence of a current hearing loss disability as defined by 38 C.F.R. § 3.385; (2) in-service incurrence or aggravation of a disease or injury that would affect the auditory system; and (3) a causal relationship between the current hearing loss disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hensley v. Brown, 5 Vet. App. 155, 159-160 (1993). Service connection may be granted on a secondary basis for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). In this case, the Veteran has a current diagnosis of right hear conductive hearing loss that meets the disability standard set forth in 38 C.F.R. § 3.385. See May 2017 VA examination report. The Board notes that because the disability was diagnosed during the pendency of this case, the element is satisfied even if the condition has since resolved. See Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Therefore, the “current disability” element of service connection has been established. Additionally, in-service exposure to acoustic trauma has been conceded. The Veteran’s military occupation specialty was aviation boatswain mate and aircraft handling. See DD-Form 214. Therefore, the “in-service incurrence” element has been established. Accordingly, the question for the Board is whether there is a causal nexus between the Veteran’s current conductive hearing loss disability and the conceded in-service acoustic trauma or some other in-service auditory injury or disease. Godfrey v. Derwinski, 2 Vet. App. 352, 356 (1992). The Board finds that the preponderance of the evidence weighs against finding such a causal relationship. A Veteran is not required to show that hearing loss was present during service if a nexus can be established between an in-service auditory injury or disease and a qualifying present hearing loss disability. Id.; 38 C.F.R. § 3.385. When there has been an in-service auditory injury or disease, evidence of upward threshold shifts during service is probative nexus evidence that must be considered together with the other record evidence to determine whether there is a medically sound basis to attribute the post-service disability to the in-service injury or disease rather than to an intercurrent cause. See Hensley, 5 Vet. App. at 159-60. At the outset, the Board notes that conductive hearing loss is caused by blockages or structural problems of the external auditory canal or the middle ear such as a punctured ear drum, fluid in the middle ear, or an accumulation of wax. On the other hand, sensorineural hearing loss is caused by damage to the vestibulocochlear nerve or to the inner ear where sound vibrations are translated into nerve impulses. The Merck Manual, 2318 (16th ed. 1992); C&P Medical EPSS, Ear (Diagnostic Code 6100-Hearing Impairment). As such, conductive hearing loss is not a chronic disease subject to presumptive service connection principles as an “organic disease of the nervous system” under 38 C.F.R. §§ 3.303(b), 3.307(a), and 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board further notes that noise-induced (prolonged) and acoustic trauma-induced (sudden explosion or loud noise) hearing loss are sensorineural in nature. With conductive hearing loss, speech discrimination scores remain normal and sounds seems lower. Speech discrimination scores are reduced with sensorineural hearing loss. The Merck Manual, 2321-22, 2340 (16th ed. 1992); C&P Medical EPSS, Ear (Diagnostic Code 6100-Hearing Impairment). A review of the Disability and Benefits Questionnaire form indicates that speech recognition scores between 94-100 are considered excellent (normal), and hearing loss is present when auditory thresholds exceed 25 decibels (dB) at any frequency between 500-4000 hertz (Hz). See also Hensley, 5 Vet. App. at 157 (noting that the threshold for normal hearing is from 0 to 20 dB, and higher threshold levels indicate some degree of hearing loss). Turning to the evidence of record, pre-service treatment records and service treatment records (STRs) show that the Veteran had a self-reported history of bilateral ear pain and recurrent ear infections since childhood; as well as clinically observed tympanic membrane abnormalities, and medically diagnosed sinusitis, otitis media and eustachian tube dysfunction. However, the Veteran’s only in-service complaint for right ear hearing loss occurred in March 2012 during an acute otitis media episode, where she described sound as “muffled.” An April 2012 ear examination showed no hearing abnormalities and she denied hearing loss in October 2013 and at separation in September 2015. See STRs. The Veteran’s audiogram test results from January 2012, August 2012, August 2013, July 2014, and August 2015 show variable upward shifts of 5-15 dB in tested thresholds between 500 and 4000 hertz. She also had variable upwards shifts of 5 dB to 20 dB at 6000 Hz, including at separation. At separation, her audiogram test results showed upward threshold shifts of 5 dB at 500 and 4000 Hz, and 10 dB at 2000 Hz. None of the in-service threshold shifts were deemed significant and she did not have hearing loss as defined by VA regulation. See STRs. The Veteran was afforded a VA examination for hearing loss in March 2017. The examination of the right ear revealed a speech discrimination score of 96 percent and puretone thresholds of 35-50 dB at all frequencies between 500 Hz and 8000 Hz, with no abnormal permanent positive threshold shifts. Tympanometry findings indicated abnormal acoustic immittance in the right ear. The Veteran was diagnosed with conductive, rather than sensorineural hearing loss in the right ear. A November 2019 VA examination of the right ear revealed a speech discrimination score of 96 percent and puretone thresholds of 15-25 dB at all frequencies, with normal hearing and abnormal permanent positive threshold shifts. The examiner stated that the abnormal March 2017 tympanogram with conductive hearing loss in the right ear was consistent with an outer and/or middle ear condition that appeared to have resolved. There are four negative medical nexus opinions in this case from March 2017, May 2018, November 2019, and September 2020. Three were deemed inadequate, primarily because they heavily relied on the fact that the Veteran did not have hearing loss at any point other than in March 2017. Nonetheless, taken together with the other evidence of record, the several VA opinions establish that the Veteran’s current conductive hearing loss disability is not at least as likely as not related to an in-service injury, event, or disease, including acoustic trauma. The March 2017 VA examiner explained that conductive hearing loss is not indicative of noise-induced hearing loss. The May 2018 examiner added that the present conductive hearing loss disability could not have been a continuation of the May 2012 otitis media episode because the symptoms did not persist beyond the isolated episode. Further, the current disability was not attributable to acoustic trauma because conductive hearing loss is caused by outer and/or middle ear pathology other than noise exposure, while noise-induced (sensorineural) hearing loss is the result of damage to the inner ear structure. Additionally, there would have been significant permanent threshold shifts noted in the Veteran’s in-service audiograms for hearing loss resulting from acoustic trauma. The November 2018 examiner indicated that the March 2017 condition was acute given that the Veteran’s hearing subsequently returned to normal. Finally, the September 2020 examiner added that inner ear hearing should not change after noise exposure is removed, thus delayed onset hearing loss is not applicable to military noise exposure. The examiner also noted the Veteran’s recurrent ear infections since childhood and emphasized the Veteran’s “nonexistent” hearing loss in an apparent attempt to highlight that “hearing loss” is a term of art. The examiners’ combined opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Based on the foregoing, the Board finds that the Veteran did not sustain a sensorineural injury to the right ear as a result of in-service acoustic trauma exposure. She did not have substantial threshold shifts at any time during service. After service, her speech recognition scores were excellent even during her most severe hearing loss, which is inconsistent with sensorineural hearing loss. Although she had upward threshold shifts during service, they subsequently returned to lower levels, which the September 2020 examiner explained is inconsistent with an inner ear (sensorineural) condition. Other than in March 2017, the Veteran did not have medically-defined hearing loss any time before, during or after her military service. The variability of her audiogram test results indicates a non-fixed pathology. Considering the Veteran’s history of acute ear infections since childhood, her isolated and temporary hearing loss episode, and the composite VA medical opinion, the Board finds that her right ear conductive hearing loss was not the result of chronic or ongoing condition that began in or was related to service. The Board also notes that service connection for otitis media is not in effect. Because the Veteran’s otitis media is not a service-connected disability, it cannot form the basis for secondary service connection for her right ear hearing loss. Consequently, the Board finds that the preponderance of the evidence is against a finding that the Veteran’s right ear hearing loss began during service or is otherwise related to an in-service injury, event, or disease. See Hensley, 5 Vet. App. at 159-60. Based on the foregoing, the Board concludes that the criteria for service connection for right ear hearing loss have not been met. Accordingly, service connection for right ear hearing loss is not warranted and the Veteran’s claim is denied. C. CRAWFORD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Jones, Catherine J. 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.