Citation Nr: 21013715 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 17-45 303 DATE: March 10, 2021 ORDER Service connection for bilateral hearing loss is granted. FINDING OF FACT Resolving reasonable doubt in the Veteran’s favor, his bilateral sensorineural hearing loss was caused by his service-connected ankylosing spondylitis. CONCLUSION OF LAW The criteria for service connection for bilateral hearing loss, as secondary to ankylosing spondylitis, are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served in the Army from February 1969 to December 1970. This matter initially came before the Board of Veterans’ Appeals (Board) on appeal from a November 2015 rating decision. In November 2019, the Board issued a decision that reopened the previously denied claim and remanded the issue. 1. Service connection for bilateral hearing loss As noted in the prior remand, the Veteran primarily contends that his bilateral hearing loss is related to his service-connected ankylosing spondylosis condition. In addition, he contends that he has experienced diminished hearing since service. Direct service connection will be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Secondary service connection will be granted if the evidence demonstrates that a current disability is proximately due to or the result of, or is aggravated beyond its natural progression, by service-connected disability. 38 C.F.R. § 3.310. In adjudicating such claims, reasonable doubt that exists because of an approximate balance of positive and negative evidence concerning any point will be resolved in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Medical evidence establishes current bilateral sensorineural hearing loss disability that meets the VA disability criteria in 38 C.F.R. § 3.385 based on pure tones and speech scores, to include in May 2011 and August 2016 VA examinations. The weight of the evidence does not establish entitlement to direct service connection based on hazardous noise exposure during service, which is shown through the Veteran’s service duties as an armor intel specialist in Vietnam. Because a full grant of service connection is warranted based on secondary causation, it is unnecessary to further discuss these contentions or evidence. The Veteran reported during his 2016 VA examination that he first noticed hearing loss about 15 years earlier in 2001. This is generally consistent with his June 2001 treatment for hearing loss with objective shifts in pure tone thresholds as noted in private treatment records received from his post-service employer. The evidence also includes baseline audiology results from 1986 and a comparison in 1995, and the Veteran was counselled in 1996 due to change in hearing potentially due to occupational noise exposure. The June 2001 records noted review of the current and prior hearing tests, and stated that the Veteran did have hearing loss, but in some of the lower frequencies “he has had significant loss over the past 4-5 years.” The physician advised the Veteran to wear hearing protection, and noted that he had not really worn hearing protection on regular basis until the last 7-8 years. Auditory brainstem response (ABR) and electrocochleography (ECOG) results were normal, but an electronystagmography (ENG) was abnormal showing left-side weakness, which was indicative of left peripheral vestibular involvement. A June 2015 private opinion letter from Dr. RC, an otolaryngology provider, stated that the Veteran had a history of ankylosing spondylitis and significant hearing loss. His hearing test revealed severe sensorineural hearing loss that was fairly flat, and it was uncertain what was causing this condition. Dr. RC stated that autoimmune inner ear disease “would be a possibility,” as would noise-induced hearing loss. The Veteran also had evidence of right hydrops based on ECOG testing, and there was some family history of hearing loss in a grandfather. The Veteran submitted several medical articles in 2015 concerning potential effects of ankylosing spondylitis on hearing. These articles reflect that ankylosing spondylitis generally results in conductive hearing loss, but it may also result in sensorineural hearing loss. One article states that ankylosing spondylitis has been reported to be associated with sensorineural hearing loss in about 28 percent of patients. A second article states that more than half of patients with ankylosing spondylitis had sensorineural hearing loss, particularly in the high frequency range. The article stated that hearing loss is paralleled by abnormal immunology and is a local expression of autoimmune disease. A third article states that autoimmune disease can cause sensorineural hearing loss. A fourth article states that sensorineural hearing loss, especially at high frequencies, is common in patients with ankylosing spondylitis and may be an extra-articular feature of the disease. The article states that a long duration of disease and extraspinal involvement are important parameters for ear involvement in patients with ankylosing spondylitis. The evidence reflects that the Veteran has had longstanding ankylosing spondylitis since 1969 (as Reiter’s syndrome in service), and he has been awarded service connection for valvular heart disease as secondary to his ankylosing spondylitis. Pure tone thresholds showed both low frequency and high frequency hearing loss. The 2019 Board remand noted that neither the private opinion nor the medical articles nor alone were sufficient to establish service connection. Accordingly, the remand directed that an addendum opinion be obtained that addresses whether the Veteran’s hearing loss was caused or aggravated by his ankylosing spondylitis, with consideration of the private opinion and medical articles documents. In December 2019 and January 2021 addendum reports, a VA examiner opined that the Veteran’s hearing loss was not caused or aggravated by his service-connected ankylosing spondylitis because he has sensorineural hearing loss, and ankylosing spondylitis results in conductive hearing loss. However, these medical opinions are inadequate because they do not reflect consideration of the medical articles with notations of sensorineural hearing loss due to ankylosing spondylitis, to include where the condition is longstanding with extra-spinal involvement as in this case. Resolving reasonable doubt in the Veteran’s favor, no additional development is needed and the evidence is sufficient to establish service connection for his bilateral sensorineural hearing loss as secondary to his ankylosing spondylitis. Although there is a suggestion that his hearing loss may be due to post-service occupational noise exposure, the medical evidence is at least in relative equipoise as to whether it was caused by ankylosing spondylitis. The appeal is granted. Bethany L. Buck Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Wheatley 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.