Citation Nr: 21023761 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 16-25 833 DATE: April 21, 2021 ORDER Entitlement to service connection for bilateral hearing loss, to include secondary to his service-connected aplastic anemia, is denied. FINDING OF FACT The Veteran’s bilateral hearing loss is not secondary to service-connected aplastic anemia, and is not otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for bilateral hearing loss, to include secondary to his service-connected aplastic anemia, are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, 3.385. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Marine Corps from August 1984 to August 1988. This matter comes before the Board of Veterans’ Appeals (Board) from a December 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) and was previously remanded by the Board in October 2018, March 2020 and July 2020. Specifically, the Board directed the RO to provide etiology opinions that addressed the Veteran’s contentions, whether his left ear hearing loss was aggravated by his service and whether there is a potential relationship between the Veteran’s aplastic anemia and his hearing loss. After an adequate opinion was provided, the RO issued a supplemental statement of the case in October 2020, further denying the claims. The matters now return to the Board. Service Connection Generally, service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). A disability which is proximately due to or the result of a service-connected disease shall be service connected. 38 C.F.R. § 3.310(a). A claimant is also entitled to service connection on a secondary basis when it is shown that a service-connected disability has aggravated a nonservice-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). For Veterans who served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as organic diseases of the nervous system, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 38 C.F.R. § 3.307(a), 3.309(a); Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (the theory of continuity of symptomatology can be used only in cases involving those disabilities specified as chronic under 38 C.F.R. § 3.309(a). The threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. 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; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to service connection for bilateral hearing loss The Veteran contends that exposure to weapons fire and training are the cause of his current right ear hearing loss. See May 2016 Form 9. He states that he has left ear hearing loss from childhood. See September 2006 Treatment Note. A September 2013 VA audiological examination revealed hearing loss in the right ear for VA purposes under 38 C.F.R. § 3.385 and mixed hearing loss in his left ear; therefore, the Veteran has a current disability. Following a review of the Veteran’s service treatment records, his October 1983 entrance examination notes that he had ear, nose or throat issues and hearing loss was noted for his left ear. In April 1985, the Veteran stated that he had hearing loss throughout his life. In July 1986, it was noted that his left ear remained 40 hertz at 1000 and 2000 decibels and in August 1988 during his separation examination, hearing loss was noted. In the Veteran’s post-service treatment records, it was noted in September 2012 that the Veteran wanted to be referred to the Audiology Clinic for decreased hearing, but he was not diagnosed. In February 2016 the Veteran also complained of hearing loss. The Board has first considered whether service connection for bilateral hearing loss is warranted on a presumptive basis. However, the available evidence fails to show that the Veteran manifested bilateral hearing loss in his right ear to a compensable degree within the one year following his release from active duty. The earliest diagnosis of hearing loss in his left ear was in September 2013, more two decades after service discharge. Therefore, presumptive service connection for bilateral hearing loss is not warranted. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. In a September 2013 VA examination, the examiner opined that the Veteran’s hearing loss was less likely as not (50 percent probability or greater) caused by or a result of an event in military service. The examiner reasoned that the Veteran was a food service cook in the Marine Corps from 1984-1988. This military occupational specialty (MOS) has a low probability of noise exposure. The audiogram from the Veteran's separation examination shows no significant threshold shift when compared to his audiogram from enlistment. In the higher frequencies (3-6 kHz) his thresholds actually are significantly better at separation. As previously mentioned, the Board found this opinion to be inadequate in its October 2018 remand. This opinion is therefore afforded little, if any, probative weight. In the April 2020 VA examination, the examiner opined that the Veteran’s bilateral hearing loss was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness. In support of this conclusion, the examiner explained that for the Veteran's right ear, his entrance examination dated October 1983 showed hearing within normal limits from 500 Hz to 6 kHz as did reference and/or other hearing exams (i.e., annual and hearing conservation) dated 4/29/85, 7/23/87 and 7/29/88. Separation examination dated 8/2/88 also showed stable hearing thresholds within normal limits from 500 Hz to 6 kHz. The examiner indicated that the Veteran’s military occupational specialty (MOS) of food service specialist yielded a low probability for hazardous noise exposure; however, the Veteran's DD-214 indicated receipt of a rifle sharpshooter badge. Claims file review also indicated the Veteran reported noise exposure during basic training to both the rifle and grenade ranges. As such, at least some degree of hazardous noise exposure on active duty is conceded as is its relationship to auditory damage and hearing loss; however, there remained no objective evidence to support that a significant threshold shift (STS) - either temporary or permanent - occurred in service to suggest auditory damage was incurred from any conceded military noise. Furthermore, research has shown that hearing loss will not continue once noise exposure has stopped, and although susceptibility to noise-induced hearing loss (NIHL) is quite variable, "10 years or more of exposure is generally required for significant hearing loss to occur," (Mathur et al, 2018). Early stages of NIHL also typically manifest as a notch in hearing at 3k, 4k or 6 kHz with recovery at 8 kHz. Researchers Lie et al (2017) have indicated this notch, particularly at 4 kHz, has historically been considered a "strong indicator of NIHL" in clinical settings as well. Furthermore, Lie et al have reported NIHL is "modest compared to the effects of age-related hearing loss, particularly in older subjects." Therefore, taking into consideration the commonly accepted notched pattern seen in NIHL, the Veteran's hearing thresholds obtained on all exams during active duty service are not consistent with an audiometric configuration that would suggest noise-induced damage. As previously noted, the prevalence of hearing loss increases with age as well and is the "third most common chronic condition" reported in older adults (Krishnamurti, 2009). The American Speech-Language-Hearing Association (ASHA) reported on statistics from a 2007 survey completed by the National Institute on Deafness and Other Communication Disorders (NIDCD) that indicated 29-49 percent of adults between 50-69 years of age have a hearing loss greater than 25 dB HL within the speech range (250 Hz to 6 kHz), which increases to 63 percent for adults 70 years and older. Presbycusis (age-related hearing loss) will also manifest as a high-frequency hearing loss but will continue its downward slope at 8 kHz instead of demonstrating some degree of recovery as noted in NIHL (Mirza et al, 2018). Hearing loss has been linked to numerous other medical conditions as well, including diabetes, anemia and cardiovascular disease, including hypertension and hyperlipidemia, to name but a few. A review of the Veteran's claims file indicated diagnoses of coronary artery disease, hypertension and hyperlipidemia, which suggests further confounding factors to consider in relation to the Veteran's current hearing loss. Furthermore, at least some degree of civilian occupational noise exposure must be conceded as well given the Veteran's 10-year history as a corrections officer following military service. Normal/stable hearing thresholds were clearly demonstrated during the Veteran's active duty service, including no documented STS (temporary or permanent) that would suggest noise-induced damage. There are also no other hearing exams to review between August 1988and the Veteran's initial VA audiological examination in September 2013 to objectively indicate the presence of hearing loss or its potential onset. Hazardous noise exposure on active duty has been conceded, including its relationship to auditory damage and hearing loss; however, there remains no objective evidence to suggest an onset of symptoms in service or to any compensable degree within one year of separation. This takes into account the following:1) Normal hearing thresholds on all active duty exams with no documented significant threshold shifts (temporary or permanent),2) The Veteran's h/o civilian occupational noise exposure and3) The Veteran's other documented co-morbid medical conditions. There must be a nexus of auditory damage to relate the current hearing loss to military noise exposure and not another etiology. As such, the current evidence is against a nexus in this case; therefore, it is less likely as not the Veteran's right hearing loss is related specifically to military noise exposure. For the left ear, the examiner opined that the claimed condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. For the Veteran's left ear, entrance exam dated October 1983 showed a 30-65 dB hearing loss from 500 Hz to 6 kHz. An annual hearing exam dated April 1985 continued to show a stable hearing loss through 3 kHz with an apparent improvement in thresholds at 4k-6 kHz as well as a potential conductive component. A reference exam dated July 1987 as well as a hearing conservation exam dated July 1988 showed a stable low-frequency hearing loss rising to hearing within normal limits from 3k-6 kHz as did the Veteran's separation exam dated August 1988. MOS of food service specialist yielded a low probability for hazardous noise exposure; however, Veteran's DD-214 indicated receipt of a rifle sharpshooter badge. Claims file review also indicated the Veteran reported noise exposure during basic training to both the rifle and grenade ranges. As such, at least some degree of hazardous noise exposure on active duty is conceded as is its relationship to auditory damage and hearing loss. However, the hearing loss documented upon entrance improved in the high frequencies on all subsequent active duty exams until thresholds were consistently documented as within normal limits from 3k-6 kHz. As such, while this suggests a significant threshold shift (STS) occurred in service, it is considered a negative shift indicating improvement rather than further decline. This suggests no additional auditory damage was incurred in service from any conceded military noise exposure. Furthermore, research has shown that hearing loss will not continue once noise exposure has stopped, and although susceptibility to noise-induced hearing loss (NIHL) is quite variable, "10 years or more of exposure is generally required for significant hearing loss to occur," (Mathur et al, 2018). More importantly, early stages of NIHL also typically manifest as a notch in hearing at 3k, 4k or 6 kHz with recovery at 8 kHz. Researchers Lie et al (2017) have indicated this notch, particularly at 4 kHz, has historically been considered a "strong indicator of NIHL" in clinical settings as well. Therefore, taking into consideration the commonly accepted notched pattern seen in NIHL, the Veteran's hearing thresholds obtained on all exams during active duty service are not consistent with an audiometric configuration that would suggest noise-induced damage. This is further supported by the report of a possible low-frequency conductive hearing loss in at least 1985 as noise exposure damages the inner ear and results in sensorineural hearing loss (SNHL). A conductive hearing loss suggests normal inner ear function with a disruption of sound transmission due to some other outer or middle ear dysfunction, which is again not consistent with NIHL. The prevalence of hearing loss increases with age as well and is the "third most common chronic condition" reported in older adults (Krishnamurti, 2009). The American Speech-Language-Hearing Association (ASHA) reported on statistics from a 2007 survey completed by the National Institute on Deafness and Other Communication Disorders (NIDCD) that indicated 29-49 percent of adults between 50-69 years of age have a hearing loss greater than 25 dB HL within the speech range (250 Hz to 6 kHz), which increases to 63 percent for adults 70 years and older. Presbycusis (age-related hearing loss) will also manifest as a high-frequency hearing loss but will continue its downward slope at 8 kHz instead of demonstrating some degree of recovery as noted in NIHL (Mirza et al, 2018). Hearing loss has been linked to numerous other medical conditions as well, including diabetes, anemia and cardiovascular disease, including hypertension and hyperlipidemia, to name but a few. According to a Vanderbilt University Medical Center Stroke Symposium (2013), hearing loss also occurs in brain stem strokes. A review of the Veteran's claims file indicated diagnoses of coronary artery disease, hypertension and hyperlipidemia as well as a hemorrhagic brain stem stroke in 1996 that affected the Veteran's left side. This all suggests further confounding factors to consider in relation to the Veteran's current hearing loss. Furthermore, at least some degree of civilian occupational noise exposure must be conceded as well given the Veteran's 10-year history as a corrections officer following military service. The Veteran had a pre-existing left hearing loss noted upon entrance in 1983 that was reported as having been present "all my life" per claims file review. Although there is also h/o STS, all available hearing exams completed on active duty consistently show an improvement in high-frequency thresholds resulting in normal hearing at separation in 1988, which is not indicative of noise damage. Hazardous noise exposure on active duty has been conceded, including its relationship to auditory damage and hearing loss; however, there remains no objective evidence to suggest an exacerbation to the Veteran's known pre-existing hearing loss in service or to any compensable degree within one year of separation. This takes into account the following:1) Improved hearing thresholds to within normal limits from 3k-6 kHz on active duty exams completed through separation,2) The Veteran's h/o civilian occupational noise exposure and3) The Veteran's other documented co-morbid medical conditions, most notably his h/o hemorrhagic brain stem stroke. There must be a nexus of auditory damage to relate the current hearing loss to military noise exposure and not another etiology. As such, the current evidence is against a nexus in this case; therefore, it is less likely as not the Veteran's pre-existing left hearing loss was further exacerbated beyond its normal progression specifically due to military noise exposure. The Board found that this opinion was inadequate in its July 2020 remand. Thus, this opinion is therefore afforded no probative weight. In the September 2020 VA examination, the examiner opined that the Veteran’s right ear hearing loss was less likely as not (50 percent probability or greater) due to his military service as a food service specialist with a rifle sharpshooter badge. No significant threshold was seen in service and hearing was within normal limits on the exit exam in 1988. If the hearing loss was due to active duty noise exposure, it would be expected to have been seen while in service or shortly afterwards, which is not the case for this Veteran. It is more likely than not the result of noise exposure and/or other factors encountered after his military service time. The examiner also opined that it was less likely as not (50 percent probability or greater) not that his pre-existing left ear hearing loss was aggravated beyond normal progression as a food service specialist with a rifle sharpshooter badge. No significant threshold shift was seen in service. The pre-existing hearing loss was not aggravated beyond normal progression since a significant threshold shift was not seen at the frequencies where the hearing loss was present prior to service. Furthermore, the examiner opined that it is less likely than not that the left ear hearing loss which clearly and unmistakably existed prior to service was aggravated beyond its natural progression by his service-connected aplastic anemia. The enlistment medical form indicated that the hearing loss had been in the left "all my life". No significant threshold shift was seen in both ears from 1983-1988. No hearing loss was seen in the right ear on the exit exam. According to Kaoru Ogawa & Jin Kanzaki (1994) Aplastic Anemia and Sudden Sensorineural Hearing Loss, Acta Oto-Laryngologica, 114:sup514, DOI: 10.3109/00016489409127568, sudden sensorineural hearing loss is seen with some patients with Aplastic Anemia, which was not the case for the Veteran. The Veteran's left hearing loss existed prior to service and is a mixed hearing loss. The Veteran indicated today that he has had it since childhood and does not know the onset or circumstance in which this hearing loss was acquired. The hearing loss in the right ear is mild and does not have the configuration of a sudden hearing loss nor did the Veteran indicate that the onset was sudden. In a September 2020 Deferred Rating, the RO directed the examiner to provide an addendum opinion that further addressed the Veteran’s bilateral hearing loss as it related to his service- connected aplastic anemia. In the October 2020 addendum opinion, the examiner opined that it is less likely than not that the Veteran’s bilateral hearing loss is proximately due to or a result of a service-connected disorder, to include aplastic anemia. In support of this conclusion, the examiner noted that the Veteran’s enlistment medical form indicated that hearing loss had been in the left ear "all my life". No significant threshold shift was seen in both ears from 1983-1988. No hearing loss was seen in the right ear on the exit exam. The previous examiner K. Willis stated that "hearing loss has been linked to numerous other medical conditions as well, including diabetes, anemia and cardiovascular disease, including hypertension and hyperlipidemia, to name but a few." She did not cite any scientific literature to support this claim. According to Kaoru Ogawa & Jin Kanzaki (1994) Aplastic Anemia and Sudden Sensorineural Hearing Loss, Acta Oto-Laryngologica, 114:sup514, 85-88, DOI: 10.3109/00016489409127568, sudden sensorineural hearing loss is seen with some patients with aplastic anemia, which was not the case for the Veteran. Rather, the Veteran's hearing loss was not a sudden hearing loss. The Veteran's left hearing loss existed prior to service and is a mixed hearing loss. The Veteran indicated today that he has had it since childhood and does not know the onset or circumstance in which this hearing loss was acquired. The hearing loss in the right ear is mild and does not have the configuration of a sudden hearing loss nor did the Veteran indicate that the onset was sudden. The Board finds the September 2020 and the October 2020 medical opinions adequate. See D'Aries v. Peake, 22 Vet. App. 97, 104 (2008); Stefl v. Nicholson, 21 Vet. App. 120 (2007) (an adequate medical examination must provide a rationale and explanation for its conclusions). The examiners considered all evidence of record after thorough review of the claims file, including lay statements properly weighed. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2009); Stefl v. Nicholson, Id. (“[A] medical opinion…must support its conclusion with an analysis the Board can consider and weight against contrary opinion”). The examiners acknowledged the Veteran’s contentions and gave an explanation as to why his etiological theories could not be supported by current medical findings. Furthermore, the medical examination reports contained clear conclusions with supporting data and a thorough rationale. See Nieves-Rodriguez v. Peake, supra. Therefore, these medical opinions are of great probative value. There are no contrary opinions of record. Although the Veteran contends that he was around weapons fires and training, the Veteran’s military occupational specialty on his DD 214 notes that he was a cook, which reduced his level of exposure to hazardous noise. Additionally, the Veteran’s left ear hearing loss did not show a worsening in service, as there were no threshold shifts noted and the Veteran’s hearing loss was not sudden in either ear which is a factor when considering whether his hearing loss was caused by his aplastic anemia. Therefore, the Veteran’s contentions are without merit. The Board has considered the Veteran’s statements, to include his assertions that his current hearing loss is related to service. As the Veteran is not shown to have medical education or experience, he is a lay person and is competent to report (1) symptoms that are observable to a layperson, e.g., diminished hearing; (2) symptoms at the time supporting a later diagnosis by a medical professional; or (3) a contemporaneous medical diagnosis. See Davidson v. Shinseki, 581 F.3d 1313 (2009). The Veteran is not competent to independently render a medical diagnosis or opine as to the specific etiology of a condition as these are medically complex issues. Thus, his lay assertions do not constitute evidence upon which service connection can be granted. In any event, the Board ultimately assigns greater probative weight to the medical evidence of record, to include the opinions rendered by a trained medical professional based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. As the preponderance of the evidence is against a finding that the current hearing loss disability is related to service, direct service connection must be denied. Thus, the preponderance of the evidence is against finding that the Veteran meets the criteria for service connection for bilateral hearing loss. In reaching the conclusion above, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. CHRISTOPHER J. O’DONNELL Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Adeyemi, B. 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.