Citation Nr: 23041002 Decision Date: 07/26/23 Archive Date: 07/26/23 DOCKET NO. 19-31 341 DATE: July 26, 2023 ORDER Service connection for tinnitus is granted. Service connection for a right foot disability, to include as secondary to service-connected residuals of right achilles tendon rupture, is denied. REMANDED Entitlement to service connection for fatty tumors of the back and/or stomach is remanded. Entitlement to service connection for a left chest disability, to include a painful knot, is remanded. Entitlement to service connection for a sinus disability, to include allergic rhinitis, is remanded. Entitlement to service connection for a bilateral hearing loss disability is remanded. FINDINGS OF FACT 1. The competent and probative evidence is at least in equipoise as to whether the Veteran's current tinnitus had its onset in or is otherwise related to active service. 2. The Veteran's right foot disability, diagnosed as plantar fasciitis and hallux valgus with degenerative changes, did not manifest within one year of separation from service, is not related to a service-connected disability, and is not otherwise related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for tinnitus are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for service connection for a right foot disability, to include as secondary to right achilles tendon rupture, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Army from June 1979 to June 1982, from approximately October 1990 to April 1991, from December 1995 to July 1996, and from January 2004 to March 2005 including service in Southwest Asia. The Veteran also had several periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA) during his service in the United States Army Reserve. This appeal comes before the Board of Veterans' Appeals (Board) from an October 2016 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO) which, in pertinent part, denied service connection for tinnitus, fatty tumors of the back and stomach, a left chest disability, a sinus disability, a right foot disability, and a bilateral hearing loss disability. The Veteran's notices of disagreement (NODs) were received in November 2016 and October 2017. The RO issued the statements of the case (SOCs) in September 2019 and October 2019, and the Veteran's VA Form 9, substantive appeals were received in October 2019. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Service connection requires competent evidence showing: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). In addition, certain diseases are presumed to have been incurred in service if manifested to a compensable degree within one year after service. The presumption is rebuttable by probative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). When chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim for such diseases. 38 C.F.R. § 3.303 (b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Establishing a service connection on a secondary basis requires evidence sufficient to show: (1) that a current disability exists; and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). When service records are not available, there is a heightened obligation to assist the Veteran in the development of the case, a heightened obligation to explain findings and conclusions, and a heightened duty to carefully consider the benefit of the doubt rule. Washington v. Nicholson, 19 Vet. App. 362 (2005). The law does not, however, lower the legal standard for proving a claim for service connection but rather increases the Board's obligation to evaluate and discuss in its decision all the evidence that may be favorable to the claimant. See Russo v. Brown, 9 Vet. App. 46 (1996). 1. Entitlement to service connection for tinnitus. The Veteran asserts that he has tinnitus due to service. Specifically, he asserts that he has tinnitus related to loud combat noise he experienced during his deployments to Southwest Asia, aircraft noise, as well as loud equipment noise. See October 2019 VA Form 9; see also October 2019 VA examination report. He has also described experiencing symptoms of tinnitus during active service. See October 2019 VA Form 9. The Veteran's service personnel records and DD-214s reflect multiple marksmanship badges as well as multiple deployments to combat zones. See generally service personnel records; see also January 2023 VA memorandum. As such, the Veteran's statements that he was exposed to hazardous noise from weapons, explosives, aircraft, heavy equipment, and diesel engines are wholly consistent with the circumstances and conditions of his service. The Veteran also has a current diagnosis of tinnitus. See, e.g. October 2019 VA examination report. The key question is whether the Veteran's tinnitus arose during active service or is otherwise related to his in-service noise exposure. When a claim involves a diagnosis based on purely subjective complaints, the Board is within its province to weigh the Veteran's testimony and determine whether it supports a finding of service incurrence and continued symptoms since service. Barr v. Nicholson, 21 Vet. App. 303, 310 (2007). If it does, such testimony is sufficient to establish service connection. Id. Here, the Board finds that the Veteran's reports, during his October 2019 VA examination and in multiple lay statements regarding the in-service onset and continuation of his tinnitus are sufficient to establish service connection for that disability. Notably, there is no opinion to the contrary. The October 2019 VA examiner stated that they were unable to render an opinion regarding the etiology of the Veteran's tinnitus as his STRs are largely unavailable for review. Thus, affording the Veteran the benefit of the doubt, the Board finds that all three elements of service connection are met and that service connection for tinnitus is warranted. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 2. Entitlement to service connection for a right foot disability, to include as secondary to service-connected residuals of right achilles tendon rupture. The Veteran seeks service connection for a right foot disability. He asserts that his current right foot disabilities, diagnosed as plantar fasciitis, hallux valgus and degenerative arthritis, are the result of, or have been aggravated by, his service-connected residuals of right achilles tendon rupture. VA treatment records reveal that the Veteran suffered a right achilles tendon rupture during a period of active duty, and he is in receipt of service connection for right achilles tendon rupture. However, the available medical evidence does not reveal complaints of, or treatment for, a right foot disability during a period of active duty or inactive duty for training. The Board recognizes that the Veteran's STRs are largely unavailable and that other issues are being remanded herein, in part, to attempt to obtain outstanding STRs. However, here, the Veteran does not contend that his current right foot disabilities were incurred during active service or related to an undocumented right foot injury nor does the evidence suggest that this is the case. Instead, the Veteran claims that his current right foot disabilities are the result of his service-connected right achilles tendon rupture. The Veteran underwent a VA Ankle Conditions examination in August 2019. The Veteran recounted that he injured his right ankle while playing basketball in Korea in January 1998 while on active duty for training. He was put on bedrest for 4 days but continued to experience pain and swelling. He was diagnosed with ruptured achilles tendon later in January and underwent surgery to repair his right ankle. The right ankle healed well with no complications. The Veteran reported that he walks with his right foot toes outward. He stated that he began having pain in his right ankle approximately 5 years after the in-service right ankle injury. The Veteran stated his ankle pain is not constant but is present daily. Range of motion testing was normal. The VA examiner stated that the Veteran had surgery for his ruptured right achilles tendon which has healed with no complications or sequelae. The examiner stated that the Veteran has no current residual disability due to his in-service right achilles tendon rupture. The Veteran underwent a VA Foot Conditions examination in December 2019. The VA examiner provided diagnoses of right hallux valgus and right foot degenerative arthritis. The examiner concluded that the Veteran's right foot disability is less likely than not proximately due to his service-connected residuals of right achilles tendon rupture. The examiner noted that, during the August 2019 VA Ankle Conditions examination, the Veteran was noted to have no sequelae or current residual disability due to right achilles tendon rupture. The examiner also noted that a December 2019 x-ray imaging report revealed right foot hallux valgus with degenerative changes in the right first MTP joint, which, the examiner stated, is less likely than not caused by service-connected right achilles tendon rupture. The VA examiner further noted that the Veteran has symptoms consistent with bilateral plantar fasciitis but stated that this condition is likely caused by the Veteran's reports of prolonged standing on concrete for multiple hours daily for his job. The examiner stated that medical literature indicates that reduced ankle dorsiflexion can contribute to plantar fasciitis but noted that the August 2019 VA examination revealed normal range of motion in the ankle. The Board finds that the evidence persuasively weighs against a finding that the Veteran's right foot disability is related to his service-connected right achilles tendon rupture, manifested within one year of separation from service, or is otherwise related to service. There is nothing in the record to indicate a direct relationship to service, and the evidence establishes that hallux valgus with degenerative changes of the first MTP joint and plantar fasciitis were diagnosed many years after separation from service. The Veteran claims, rather, that the disability is secondary to his service-connected right achilles tendon rupture. The August 2019 and December 2019 VA examiners both provided probative opinions explaining that the Veteran has no sequelae or current residual disability due to his right achilles tendon rupture and that the Veteran's current right foot disabilities have no relation to his service-connected right achilles tendon rupture. There is no evidence to contradict the examiners' opinions. The Board acknowledges that a medical opinion addressing the issue of secondary service connection is inadequate where it fails to adequately encompass the question of aggravation. El-Amin v. Shinseki, 26 Vet. App. 136, 141 (2013). In El-Amin, the Court held that the Board's conclusion that a medical examination was adequate was clearly erroneous where the examiner only stated that the claimed condition was "related to" other factors. See El-Amin, 26 Vet. App. at 140. Terms such as "caused by" or "the result of" do not encompass aggravation because "[t]hese options do not permit the examiner to opine on any question other than one of direct causation." Id. at 140-41. Here, while the December 2019 medical specialist did not provide an explicit opinion regarding aggravation, the specialist's rationale clearly encompasses the question of aggravation as the specialist found no mechanism for a causal relationship between right achilles tendon rupture and the Veteran's current right foot disabilities such that the service-connected right achilles tendon rupture could have any effect on the Veteran's right foot disabilities. As such, the VA medical opinions of record are the most probative evidence of record. For these reasons, the Board finds that the evidence persuasively weighs against a finding that the Veteran's right foot disability is related to his service-connected right achilles tendon rupture, manifested within one year of separation from service, or is otherwise related to service. Service connection is therefore denied. REASONS FOR REMAND 1. Entitlement to service connection for fatty tumors of the back and/or stomach is remanded. 2. Entitlement to service connection for a left chest disability, to include a painful knot, is remanded. The Veteran seeks service connection for fatty tumors of the back and/or stomach and a left chest disability. In accordance with the duty-to-assist provisions codified at 38 U.S.C. § 5103A (d) and by regulation found at 38 C.F.R. § 3.159(c)(4), a medical opinion or examination is required if the information and evidence of record does not contain sufficient evidence to decide the claim, but there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies; and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability. McLendon v. Nicholson, 20 Vet. App. 79 (2006). A "Persian Gulf veteran" is one who served in the Southwest Asia Theater of operations during the Persian Gulf War. See 38 C.F.R. § 3.317 (e)(1). The Southwest Asia Theater of operations refers to Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317 (e)(2). As noted in a January 2023 VA Memorandum, the Veteran meets the statutory definition of Persian Gulf Veteran, based on service in the Southwest Asia theater of operations between August 2, 1990 and July 31, 1991. Thus, the Veteran is entitled to a presumption of in-service toxic exposure. See 38 U.S.C. § 1117, 1119. In February 2008, the Veteran was noted as having a nontender lipoma approximately 15 millimeters in diameter on his right mid back. See February 2008 VA treatment note. In August 2009, the Veteran reported a cyst on his right flank and noted that he had a history of fatty lipomas. See August 2009 VA treatment note. During the pendency of the appeal, the Veteran has continued to report raised areas on his torso. See July 2016 VA treatment note. The Veteran has also reported experiencing chest pain. See VA treatment records dated in April 2018 and May 2018; see also October 2019 VA Form 9. Under the recently enacted PACT Act, VA is required to provide a disability examination and medical nexus opinion when a veteran submits a compensation claim and has evidence of a disability and participation in a toxic exposure risk activity (TERA), but the evidence is not sufficient to establish service connection for the disability. See 38?U.S.C. §?1168(a) (see PACT Act, Sec. 303). That provision provides, in pertinent part: (a)(1) Medical examinations and medical opinions.-Except as provided in subsection (b), if a veteran submits to the Secretary a claim for compensation for a service-connected disability under section 1110 of this title with evidence of a disability and evidence of participation in a toxic exposure risk activity [TERA] during active military, naval, air, or space service, and such evidence is not sufficient to establish a service connection for the disability, the Secretary shall- (A) provide the veteran with a medical examination under section 5103A(d) of this title; and (B) obtain a medical opinion (to be requested by the Secretary in connection with the medical examination under subparagraph (A)) as to whether it is at least as likely as not that there is a nexus between the disability and the toxic exposure risk activity [TERA]. Id. (emphasis added). Here, the Board finds that the Veteran participated in a TERA for purposes of the provision above. Specifically, the PACT Act defines a TERA to mean "any activity- (i) that requires a corresponding entry in an exposure tracking record system (as defined in section 1119(c) of this title) for the veteran who carried out the activity; or (ii) that the Secretary determines qualifies for purposes of this subsection when taking into account what is reasonably prudent to protect the health of veterans." The provision 38?U.S.C. §?1119(c) (established by the PACT Act, Sec. 302) defines "exposure tracking record system," in pertinent part, as "...any system, program, or pilot program used by the Secretary of [VA] or the Secretary of Defense to track how veterans or members of the Armed Forces have been exposed to various occupational or environmental hazards..." Section 808 of the PACT Act requires the Secretary of VA to submit to the appropriate Congressional committees a report detailing the total number of "covered veterans," which, for purposes of that subsection, means a veteran who deployed to the Southwest Asia theater of operations any time after August 1990 and who submits a VA disability compensation claim. See PACT Act Sec. 808, Burn Pit Transparency. Since the Veteran here is a "covered Veteran" for purposes of Sec. 808 of the PACT Act - which requires VA to track data regarding veterans exposed to various airborne hazards (including burn pits) - he participated in a TERA. Moreover, the Veteran was presumptively exposed to identified substances, chemicals, and airborne hazards based on his active service in Southwest Asia after August 2, 1990. See PACT Act, Sec. 302 (adding new provision, 38?U.S.C. §?1119(b)(1), which establishes presumption of toxic exposure for members who served in certain locations; see also id. §?1119(c)(1)(A)(ii)). Therefore, 38?U.S.C. §?1168(a) requires both a VA examination and a nexus opinion regarding whether the Veteran's claimed disabilities are etiologically related to his conceded TERA. Based on the foregoing, remand is necessary to provide VA examinations as well as opinions addressing whether the claimed disabilities are etiologically related to the Veteran's conceded participation in a TERA. 3. Entitlement to service connection for a sinus disability, to include allergic rhinitis, is remanded. The Veteran contends that he is entitled to service connection for a sinus disability, to include allergic rhinitis. On enlistment in March 1979, the Veteran's nose and sinuses were assessed as normal. See March 1979 Report of Medical Evaluation. In May 2007, the Veteran reported that he had just retired from the United States Army in November 2006. He reported a history of child asthma. See May 2007 VA treatment note. VA treatment records reveal complaints of sinus congestion, productive and nonproductive coughing, and sinus tenderness. See VA treatment records dated in March 2015 and February 2016. The Veteran underwent a VA examination in December 2019. The VA examiner provided a diagnosis of allergic rhinitis. The examiner noted that the Veteran is claiming service connection for allergies related to service in Southwest Asia. The Veteran reported having issues with allergies as well as asthma growing up but was not treated with any medications. He stated that he felt like his symptoms improved initially during service due to better conditioning but worsened when he was stationed in Germany. He stated that he currently treats his allergic rhinitis with sudafed and over the counter nasal saline spray. The Veteran stated that he has ongoing nasal dryness and drainage, frequent sneezing, and an intermittent cough. The VA examiner opined that the Veteran's claimed allergy condition pre-existed service and is less likely as not proximately due to or the result of service in Southwest Asia. For rationale, the examiner noted that the Veteran reported asthma and allergies as a child. The examiner also stated that VA medical records and available STRs are silent for a diagnosis of allergies or treatment for allergies. The examiner also stated that there is no medical evidence indicating aggravation of the Veteran's allergies by service in Southwest Asia. For rationale, the examiner noted that he is not currently prescribed any medications for allergies and VA records are silent for allergies. The December 2019 VA medical opinion is inadequate because it fails to address the appropriate legal standards. On enlistment, the Veteran's ears and eardrums were assessed as normal and thus the presumption of soundness applies. To rebut this presumption, it must be found that the Veteran's current allergic rhinitis clearly and unmistakably pre-existed service. See 38 C.F.R. § 3.304(b). If found to pre-exist service, it must then be determined that the allergic rhinitis clearly and unmistakably was not aggravated beyond natural progression by active service. No opinion of record adequately addresses these questions. Moreover, the December 2019 VA medical opinion relies on an absence of evidence in treatment records to provide a negative nexus to service. Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim). In this regard, while VA treatment records do not contain a diagnosis of allergic rhinitis, they do contain multiple complaints of sinus symptoms. See VA treatment records dated in March 2015 and February 2016. Finally, as noted above, the Veteran meets the statutory definition of Persian Gulf Veteran, based on service in the Southwest Asia theater of operations between August 2, 1990 and July 31, 1991. See January 2023 VA Memorandum. Thus, the Veteran is entitled to a presumption of in-service toxic exposure. See 38 U.S.C. § 1117, 1119. As such, the addendum opinion obtained on remand must also address whether the Veteran's allergic rhinitis is etiologically related to the Veteran's conceded participation in a toxic exposure risk activity (TERA). 4. Entitlement to service connection for a bilateral hearing loss disability is remanded. The Veteran seeks service connection for a bilateral hearing loss disability. Specifically, he asserts that he has bilateral hearing loss related to loud combat noise he experienced during his deployments to Southwest Asia, aircraft noise, as well as loud equipment noise. See October 2019 VA Form 9; see also October 2019 VA examination report. The Veteran's service personnel records and DD-214s reflect multiple marksmanship badges as well as multiple deployments to combat zones. See generally service personnel records; see also January 2023 VA memorandum. As such, the Veteran's statements that he was exposed to hazardous noise from weapons, explosives, aircraft, heavy equipment, and diesel engines are wholly consistent with the circumstances and conditions of his service. The Veteran underwent a VA examination in October 2019. The VA examiner provided a diagnosis of bilateral hearing loss for VA purposes. The examiner determined an opinion could not be rendered without resorting to speculation. They noted that the Veteran's enlistment examination in 1979 revealed normal to near-normal hearing sensitivity at all frequencies in both ears. However, the examiner further noted that there are no other records pertaining to the Veteran's hearing during a period of active service anywhere in the file and stated that, without the ability to review all pertinent audiological records, an opinion regarding the etiology of the Veteran's hearing loss cannot be rendered without resorting to speculation. The Board finds the October 2019 VA opinion is inadequate. In Hensley v. Brown, 5 Vet. App. 155, 157 (1993), the Court of Appeals for Veterans Claims (Court) makes clear that a lack of objective evidence of hearing loss during military service, or at separation from service, is not fatal to a service connection claim. Evidence of a current hearing disability (i.e., one meeting the requirements of 38 C.F.R. § 3.385, as noted above) and a medically sound basis for attributing such disability to service may serve as a basis for a grant of service connection for hearing loss. As the examiner relied on the lack of audiograms in service and indicated an opinion could not be rendered without resorting to speculation based on the lack of records, an addendum opinion is warranted. Finally, as noted in the introduction, the Veteran has several nonconsecutive periods of active duty as well as many periods of ACDUTRA and INACDUTRA. VA has verified that the Veteran served on active duty in the United States Army from June 1979 to June 1982, from December 1995 to July 1996 and from January 2004 to March 2005. See DD Forms 214, Certificates of Release or Discharge from Active Duty. However, the Veteran's periods of ACDUTRA and INACDUTRA are unclear, and several pieces of evidence indicate that the Veteran likely had an additional period of active duty service. Service personnel records indicate that the Veteran was deployed to Saudi Arabia from October 30, 1990, to April 25, 1991. See Record of Assignments. The same document indicates that the Veteran was ordered to active military service at the direction of the United States President in October 1990. A DD Form 214 reflecting this period of active duty is not of record. Additionally, while a formal finding was made in August 2019 certifying that the Veteran's STRs are complete and that no further records exist, it does not appear that this search considered the Veteran's period of active duty from October 1990 to approximately April 1991. Notably, the immediately preceding VA Form 21-3101 Request for Information does not request STRs or personnel records related to this period of service. See June 2019 VA 21-3101 Request for Information. As such, additional attempts should be made on remand to obtain any outstanding STRs and service personnel records, as well as to verify the Veteran's periods of service. The matters are REMANDED for the following action: 1. Verify the Veteran's periods of active service, active duty for training, and inactive duty for training with respect to his Reserve service through all appropriate sources. Reports of retirement points do not contain the necessary information in this regard. Any negative search results should be noted in the record and communicated to the Veteran pursuant to 38 C.F.R. § 3.159(e). 2. Obtain the Veteran's complete service treatment records for each period of verified active duty, ACDUTRA, and INACDUTRA service, to include preparation of a final notification letter to the Veteran of an inability to obtain his substantially complete service treatment records, if warranted. 3. Schedule the Veteran for a VA examination with an appropriate medical specialist to determine the nature and etiology of any fatty tumors/lipomas, to include of the back or stomach. All necessary tests should be performed. The examiner must review the claims file, including the service treatment records and post-service treatment records, in conjunction with the examination. For each diagnosed fatty tumor or lipoma, the medical specialist is requested to address or provide an opinion as to whether it is at least as likely as not (evidence in at least approximate balance) that the fatty tumor or lipoma had its onset in or is otherwise related to the Veteran's active service, to include his conceded toxic exposure risk activities (TERA) during his deployment to Saudi Arabia in 1990-1991 and his deployment to Kuwait in 2004-2005. The examiner must address the synergistic, combined effect of all of the Veteran's TERAs. In rendering each requested opinion, the medical specialist must consider and discuss all service treatment records and post-service medical and other objective evidence of record. The medical specialist also must consider and discuss all lay assertions, to include any assertions as to in-service events, and as to the nature, onset, and continuity of symptoms. Notably, the absence of documented evidence of a specific disability or associated symptoms during and shortly after service should not, alone, serve as the sole basis for a negative opinion. In this regard, the medical specialist is advised that the Veteran is competent to report his observable symptoms and history, and such reports must be specifically acknowledged and considered in formulating opinions. If lay assertions in any regard are discounted, the medical specialist should clearly so state, and explain why. The medical specialist must provide a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the specialist must state this and provide a rationale for such conclusion. In remanding this matter, no finding is made, implicit or otherwise, as to the credibility of the Veteran's assertions. Neither the Veteran's credibility nor any lack thereof should be presumed in this remand. 4. Schedule the Veteran for a VA examination with an appropriate medical specialist to determine the nature and etiology of any chest disability or functional impairment, to include the Veteran's reports of painful chest knots. All necessary tests should be performed. The examiner must review the claims file, including the service treatment records and post-service treatment records, in conjunction with the examination. For each diagnosed chest disability, the medical specialist is requested to address or provide an opinion as to whether it is at least as likely as not (evidence in at least approximate balance) that the chest disability had its onset in or is otherwise related to the Veteran's active service, to include his conceded toxic exposure risk activities (TERA) during his deployment to Saudi Arabia in 1990-1991 and his deployment to Kuwait in 2004-2005. The examiner must address the synergistic, combined effect of all of the Veteran's TERAs. In rendering each requested opinion, the medical specialist must consider and discuss all service treatment records and post-service medical and other objective evidence of record. The medical specialist also must consider and discuss all lay assertions, to include any assertions as to in-service events, and as to the nature, onset, and continuity of symptoms. Notably, the absence of documented evidence of a specific disability or associated symptoms during and shortly after service should not, alone, serve as the sole basis for a negative opinion. In this regard, the medical specialist is advised that the Veteran is competent to report his observable symptoms and history, and such reports must be specifically acknowledged and considered in formulating opinions. If lay assertions in any regard are discounted, the medical specialist should clearly so state, and explain why. The medical specialist must provide a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the specialist must state this and provide a rationale for such conclusion. In remanding this matter, no finding is made, implicit or otherwise, as to the credibility of the Veteran's assertions. Neither the Veteran's credibility nor any lack thereof should be presumed in this remand. 5. Obtain a medical opinion for the service connection claim for a sinus disability, to include allergic rhinitis, from an appropriate medical specialist. Only arrange for the Veteran to undergo an examination if deemed necessary in the judgment of the medical specialist designated to provide the medical opinion. The entire, electronic claims file to include a complete copy of this REMAND must be made available to the designated individual, and the medical opinion report should include discussion of the Veteran's documented history and assertions. If the Veteran is examined, all indicated tests and studies should be accomplished (with all results made available to the examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. For each sinus disability diagnosed during the pendency of the claim including allergic rhinitis, the medical professional should respond to the following: (a) Is it clear and unmistakable (undebatable) that the sinus disability pre-existed a period of active service? (1) If the pre-existing sinus disability is determined to be congenital, explain whether the condition is a congenital defect or disease. For VA purposes, a congenital disease generally refers to a condition considered capable of improving or deteriorating, whereas a congenital defect generally refers to a condition not considered capable of improving or deteriorating. (a) If a sinus disability is determined to be a congenital disease, opine whether it is clear and unmistakable (undebatable) that the sinus disability WAS NOT aggravated (non-temporary increase in severity) during active service or whether it is clear and unmistakable (undebatable) that any increase was due to the natural progress of the disability. (b) If a sinus disability is determined to be a congenital defect, opine whether it is at least as likely as not (evidence in at least approximate balance) the Veteran incurred a superimposed injury or disease during active service that resulted in additional disability of the sinuses. (2) If a sinus disability is found to clearly and unmistakably pre-exist service, but not be congenital, opine whether it is clear and unmistakable (undebatable) that the sinus disability WAS NOT aggravated (non-temporary increase in severity) during a period of active service or whether it is clear and unmistakable (undebatable) that any increase was due to the natural progress. (f.) If a sinus disability was found to not clearly and unmistakably pre-exist service, opine whether it is at least as likely as not (evidence in at least approximate balance) that the disability had its onset during active service or is otherwise etiologically related to his active service to include his conceded toxic exposure risk activities (TERA) during his deployment to Saudi Arabia in 1990-1991 and his deployment to Kuwait in 2004-2005. The examiner must address the synergistic, combined effect of all of the Veteran's TERAs. In rendering the requested opinions, the medical specialist must consider and discuss all service treatment records and post-service medical and other objective evidence of record. The medical specialist also must consider and discuss all lay assertions, to include any assertions as to in-service events, and as to the nature, onset, and continuity of symptoms. The medical specialist should specifically address the Veteran's lay statement wherein he reported that he began experiencing sinus/allergy problems while serving in the Gulf and has continued to suffer with sinus/allergy problems since that time. Notably, the absence of documented evidence of a specific disability or associated symptoms during and shortly after service should not, alone, serve as the sole basis for a negative opinion. In this regard, the medical specialist is advised that the Veteran is competent to report his observable symptoms and history, and such reports must be specifically acknowledged and considered in formulating opinions. If lay assertions in any regard are discounted, the medical specialist should clearly so state, and explain why. The medical specialist must provide a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the specialist must state this and provide a rationale for such conclusion. In remanding this matter, no finding is made, implicit or otherwise, as to the credibility of the Veteran's assertions. Neither the Veteran's credibility nor any lack thereof should be presumed in this remand. 6. Obtain a medical opinion for the service connection claim for bilateral hearing loss from an appropriate medical specialist. Only arrange for the Veteran to undergo an examination if deemed necessary in the judgment of the medical specialist designated to provide the medical opinion. The entire, electronic claims file to include a complete copy of this REMAND must be made available to the designated individual, and the medical opinion report should include discussion of the Veteran's documented history and assertions. If the Veteran is examined, all indicated tests and studies should be accomplished (with all results made available to the examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. The medical professional should address whether it is at least as likely as not (evidence in at least approximate balance) that the Veteran's bilateral hearing loss had its onset in or is otherwise related to the Veteran's active military service, to include his conceded in-service noise exposure to weapons, explosives, aircraft, heavy equipment, and diesel engines. In rendering the requested opinion, the medical specialist must consider and discuss all service treatment records and post-service medical and other objective evidence of record. The medical specialist also must consider and discuss all lay assertions, to include any assertions as to in-service events, and as to the nature, onset, and continuity of symptoms. In this regard, the medical specialist is advised that the Veteran is competent to report his observable symptoms and history, and such reports must be specifically acknowledged and considered in formulating opinions. If lay assertions in any regard are discounted, the medical specialist should clearly so state, and explain why In rendering an opinion, the examiner is advised that the absence of in-service evidence of a hearing disability during service is not always fatal to a service connection claim. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Evidence of a current hearing loss disability and a medically sound basis for attributing that disability to service may serve as a basis for a grant of service connection for hearing loss where there is credible evidence of acoustic trauma due to significant noise exposure in service, post-service audiometric findings meeting the regulatory requirements for hearing loss disability for VA purposes, and a medically sound basis upon which to attribute the post-service findings to the injury in service. See Hensley v. Brown, 5 Vet. App. 155, 159 (1993). The medical specialist must provide a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the specialist must state this and provide a rationale for such conclusion. In remanding this matter, no finding is made, implicit or otherwise, as to the credibility of the Veteran's assertions. Neither the Veteran's credibility nor any lack thereof should be presumed in this remand. Paulette Vance Burton Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M, Victor 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.