Citation Nr: 21024130 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 07-10 240A DATE: April 22, 2021 REMANDED Entitlement to service connection for bilateral hearing loss is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1972 to November 1973. This matter comes to the Board of Veterans’ Appeals on appeal from an April 2018 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In December 2020, the Board remanded the instant matter and a claim for service connection for a cervical spine disorder. While on remand, a February 2021 rating decision awarded service connection for degenerative disc disease of the cervical spine. As such is a full grant of benefit sought on appeal with regard to such issue, it is no longer before the Board. The remaining issue now returns for further appellate review. Entitlement to service connection for bilateral hearing loss. As noted in the December 2020 remand, the Veteran contends that his currently diagnosed bilateral hearing loss is due to noise exposure coincident with his military occupational specialty (MOS) as a telephone switching equipment repairman, which required him to work on the flight deck. Further, while he was required to wear earplugs, he alleges such were insufficient hearing protection. In such remand, the Board noted that, in June 2017, J.K., a private treatment provider, opined that the Veteran’s type of hearing loss is typically due to high levels of noise exposure for prolonged periods of time. In this regard, he noted that the Veteran reported that his job in the military placed him in constant high noise level environments, which J.K. found contributed to his hearing loss. However, the Board found that, as J.K. did not consider the Veteran’s service treatment records (STRs), which reflect normal hearing at the time of his entrance and separation from service, his opinion was insufficient to award service connection. Further, the Board observed that, while May 2005, January 2010, and April 2018 VA examiners opined that the Veteran’s bilateral hearing loss was less likely as not caused by or the result of military noise exposure based on a finding that his STRs were silent for any complaint of hearing loss, and he had normal hearing on entrance and separation examinations without a significant shift in his hearing thresholds, the Veteran’s representative cited a study from the National Institutes of Health (NIH), National Institute on Deafness and Other Communication Disorders (NIDCD), that discussed how noise-induced hearing loss can take a long time to be noticeable. Thus, the Board remanded the case in order to obtain an addendum opinion addressing the etiology of the Veteran’s bilateral hearing loss that took into account such medical treatise evidence. In December 2020, a VA examiner acknowledged the Veteran’s in-service noise exposure, but opined that his bilateral hearing loss was less likely than not due to his military service. In support of such opinion, she noted his enlistment and separation examinations reflected normal hearing bilaterally, and there was no decrease in his hearing acuity from entrance to exit. The examiner further observed that audiometric evaluation in September 1990, conducted 17 years after the Veteran’s separation from service, reflected only low frequency bilateral hearing loss from 250 to 1000 Hertz with good hearing at 2000 to 8000 Hertz in both ears, thus failing to demonstrate evidence of a high frequency noise notch in either ear. She also indicated that such low frequency bilateral hearing loss was due to his post-service sporadic history of ear infections (otitis externa). Rather, the examiner found that the first indication of high frequency hearing loss was noted in the right ear in 2005 (although he still had normal hearing in the left ear), at which time the Veteran filed for service connection. Additionally, she noted that the Air Force was the first military branch to implement hearing conservation practices beginning in 1948. With respect to the NIH, NIDCD, article cited by the Veteran’s representative in September 2020, the examiner stated it was not unusual for someone to have high frequency hearing loss and not be aware of it. However, if such individual were tested, that hearing loss would be discovered and documented on the audiogram. In the instant case, the examiner again noted that the Veteran separated from the Air Force with normal bilateral hearing, and there was no evidence of noise-induced hearing loss seen on his exit audiogram, or the 1990 audiogram. Rather, the first evidence of high frequency sensorineural hearing loss (the type and configuration needed to substantiate the current claim) was not documented in the right ear until 2005. In this regard, the examiner cited the Institute of Medicine (IOM) (2006) report, which found that “[n]o longitudinal studies have examined patterns of hearing loss over time in noise-exposed humans or laboratory animals who did not develop hearing loss at the time of the noise exposure. The committee’s understanding of the mechanisms and processes involved in the recovery from noise exposure suggests that a delay of many years in the onset of noise-induced hearing loss following an earlier noise exposure is extremely unlikely.” The examiner stated such study was the most comprehensive to date, and concluded that it is “extremely unlikely” that delayed onset hearing loss exists. In this regard, she found that hearing loss from noise trauma happened immediately and, if damage to the auditory mechanism occurred from noise trauma during service, there would be some indication of it on the Veteran’s separation audiogram, which was not present (i.e., even if such were still normal, a shift in his hearing from enlistment to separation would have been expected to have been seen). Thus, the examiner concluded that it is less likely than not that the Veteran’s currently diagnosed bilateral hearing loss is caused by or a result of his military noise exposure. However, in his April 2021 Written Brief Presentation, the Veteran’s representative argued that the phenomenon of delayed onset hearing loss has been extensively researched since the IOM issued its report in 2006. In this regard, he cited a May 2015 article published in the Journal of Neuroscience that showed that auditory damage can accelerate hearing loss in aging in some cases. Specifically, the study cited stated there is a period of fairly rapid functional recovery [of hearing loss] in the hours and weeks after noise exposure, which is turn followed by a period of relative stability, giving the impression that noise, once it stops, produces no progressive or delayed consequences as exposed individuals age. Much of the evidence cited in support of this view is based on audiometric thresholds, which are generally good at reflecting damage to hair cells, but not damage to the sensory neurons innervating them, particularly when the neuropathy is subtotal or diffuse. However, the study’s authors state their recent work has shown that both aging and noise exposure have insidious consequences not revealed by standard threshold metrics, and a single episode of synaptopathic noise early in life can exaggerate dramatically the loss of cochlear synapses and cochlear neurons that otherwise occurs with age and can produce delayed loss of threshold sensitivity and outer hair cells. Further, recent work suggests that cochlear synapses, not sensory cells, are most vulnerable to acoustic injury and aging. See https://www.jneurosci.org/content/jneuro/35/19/7509.full.pdf. Furthermore, as noted by the Veteran’s representative, the examiner did not address the qualification noted in the IOM 2006 report that “[t]here is not sufficient evidence from longitudinal studies in laboratory animals or humans to determine whether permanent noise-induced hearing loss can develop much later in one’s lifetime, long after the cessation of that noise exposure” and that “definitive studies to address this issue have not been performed.” McCray v. Wilkie, 31 Vet. App. 243 (2019). Finally, the Veteran’s representative argued that, to the extent that the examiner relied upon the fact that the Air Force was the first military branch to implement hearing conservation practices beginning in 1948 in providing her unfavorable opinion, the Veteran reported that, while he received hearing protection in the form of earplugs, such was insufficient. Thus, the Board finds a remand is warranted to obtain an addendum opinion addressing the etiology of the Veteran’s bilateral hearing loss that addresses the foregoing concerns. The matter is REMANDED for the following action: Return the record, to include a copy of this Remand, to the December 2020 VA examiner who offered the most recent opinion addressing the etiology of the Veteran’s bilateral hearing loss to obtain another addendum opinion addressing such matter. If she is not available, the record should be provided to an appropriate medical professional so as to render the requested opinion. Following a review of the record, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s currently diagnosed bilateral hearing loss is related to his in-service noise exposure to the jet line/ flight deck and telephone switches coincident with his MOS of telephone switching equipment repairman? In offering such opinion, the examiner must consider the Veteran’s statements regarding the insufficiency of his military-issued hearing protection, and the Journal of Neuroscience article cited by the Veteran’s representative in his April 2021 Written Brief Presentation (and summarized above) that showed that auditory damage can accelerate hearing loss in aging in some cases. The examiner should also consider and discuss the qualification noted in the IOM 2006 report that “[t]here is not sufficient evidence from longitudinal studies in laboratory animals or humans to determine whether permanent noise-induced hearing loss can develop much later in one’s lifetime, long after the cessation of that noise exposure” and that “definitive studies to address this issue have not been performed.” A complete rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. M. Kelly, 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.