Court Opinion

ID: 4707692
Source: CourtListenerOpinion
Date Created: 2021-07-29 19:03:20.90777+00
Date Added: 2024-06-11T09:02:22.922984
License: Public Domain

Citation Nr: AXXXXXXXX
Decision Date: 06/29/21	Archive Date: 06/29/21

DOCKET NO. 210519-161007
DATE: June 29, 2021

REMANDED

Service connection for bilateral hearing loss is remanded.

Service connection for right ear infection is remanded.

 

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from March 1966 to June 1969.  The Veteran contends that he is entitled to service connection for bilateral hearing loss and service connection for right ear infection.

In April 2019, a Department of Veterans Affairs (VA) Regional Office (RO) issued a rating decision under the modernized appeals system known as the Appeals Modernization Act (AMA).  In the April 2019 rating decision, the RO denied the Veteran's claim of service connection for bilateral hearing loss.  In December 2020, the Veteran submitted a VA Form 20-0995 Decision Review Request: Supplemental Claim concerning the issues of service connection for bilateral hearing loss and service connection for right ear infection.  Accordingly, the RO issued a rating decision in January 2021, in which they considered the evidence of record prior to the issuance of the January 2021 rating decision.  In the January 2021 rating decision, the RO denied the Veteran's claims of service connection for bilateral hearing loss and right ear infection.  In May 2021, the Veteran timely appealed such rating decision to the Board by submitting a Decision Review Request: Board Appeal (Notice of Disagreement) (VA Form 10182), in which he elected the direct review lane.  Consequently, the Board's review is limited to the evidence of record at the time of the issuance of the rating decision on January 5, 2021. 38 C.F.R. § 20.303.  

The Veteran was previously denied service connection for ear infections and hearing loss.  In the decision on appeal, the RO adjudicated the merits of the issue.  The RO's treatment of these issues is consistent with a favorable finding that new and relevant evidence was received.  As there is not clear and unmistakable error in this finding, the Board will not reconsider this question.  See 38 C.F.R. § 20.801(a).  

This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C. § 7107(a)(2). 

REASONS FOR REMAND

1. Entitlement to service connection for bilateral hearing loss. 

The Veteran contends that he is entitled to service connection for bilateral hearing loss (claimed as deafness).

In the January 2021 rating decision, the AOJ favorably found that the Veteran has right ear hearing loss, as shown in an April 2019 VA examination.  The AOJ also favorably found that the Veteran was exposed to acoustic trauma during active service.  The Veteran's DD214 Certificate of Release or Discharge from Active Duty showed that his military occupational specialty was as a door gunner, which has a high probability of exposure to military noise.  

After service, the Veteran filed a claim of service connection in January 1975 for ear infection and ulcers which affected his hearing.  

In a June 1975 VA examination, the Veteran reported that, in 1968 while flying helicopters in Vietnam, he began having popping in the right ear.  Since that time, shooting pains had occurred in the right ear every month or two.  The Veteran reported some difficulty hearing conversations.  The examiner stated that the ear drums had a dull luster.  The examiner diagnosed the Veteran with chronic bilateral otitis externa (outer ear infection). 

In a March 2017 VA Internal Medicine Attending Note, the Veteran reported experiencing vertigo, and he stated that he was hard of hearing, particularly with rapid head movement.  

In a March 2017 VA Audiology Note from a few weeks later, the examiner found that the Veteran had normal hearing in the right ear and mild high frequency sensorineural hearing loss in the left ear.  The Veteran reported that, during active service in 1969, he had some fluid coming from his right ear, but he could not recall if any incident had occurred to cause the drainage.  He stated the discharge lasted a few hours and then stopped.  The Veteran reported that, currently, he was experiencing vertigo, which began three or four months ago, as well as intermittent bilateral tinnitus that began around the same time as the dizziness.  The tinnitus had a high-pitched, steady tone in both ears, and it occurred two or three times a week and could last seconds to hours. 

In an April 2017 VA Otolaryngology Consult, the examiner noted that the Veteran's tympanic membrane perforation did not appear to be affecting his hearing. 

In a July 2018 VA Audiology Note, the Veteran reported decreased right ear hearing with a pressure sensation.  The examiner found right ear unilateral conductive loss and left ear unilateral sensorineural hearing loss with mild puretone threshold changes in each ear.  In a VA Otolaryngology Note from the same day, the Veteran stated that he thinks his hearing had worsened in the past year.  The Veteran also reported that he had experienced intermittent ringing in the right ear over the past four or five years. 

In an October 2018 private treatment record, the examiner reported that a hearing test resulted in an asymmetrical worsening of hearing in the right ear.  Otoscope examination of right hear showed a central posterior right tympanic membrane perforation with dry ear canal and dry middle ear space.  The examiner gave an assessment of bilateral sensorineural hearing loss and a right tympanic membrane perforation.

In a January 2019 private treatment record, the Veteran reported that, when he was serving in Vietnam, he had an episode of right eardrum rupture and otorrhea.  He stated that, ever since then, he has occasional infrequent right ear infection.  The last ear infection was six months ago.  Ear drops were effective in resolving the right otorrhea six months ago.  For the past five months, he noticed a decrease in his right ear hearing.  He stated that he also difficulty understanding conversations in a noisy environment.

In a January 2019 VA Audiology Note, the Veteran reported improved hearing in the right ear post-surgical intervention of a right tympanic membrane perforation and infection.  

At an April 2019 VA examination for hearing loss, the VA examiner diagnosed the Veteran with bilateral sensorineural hearing loss in the frequency range of 500  4,000 Hz.  The Veteran reported a long-standing and progressive bilateral hearing loss that he first detected during active service.  He attributed the change in his hearing to the combat noise exposure he incurred as a door gunner in Vietnam.  The Veteran reported exposure to small arms fire, machine gun fire, artillery, mortars, grenades, explosives, helicopters, aircraft, flight line equipment, trucks and generators while in the military.  He had two years of combat duty in Vietnam.  During one incident, he suffered a perforated tympanic membrane in his right ear.  He was treated in the field for the injury, but it never really healed.  He denied any further noise exposure.  For years, he continued to have problems with ear infections and episodes of vertigo.  In November 2018, he had tympanoplasty surgery to repair his tympanic membrane.  He noticed a significant improvement in his hearing following the surgery, and the vertigo had been resolved.  However, about one month ago he noticed a chronic pain and a significant drop in hearing in his right ear.  He also reported that the episodes of vertigo had returned.  He also reported the onset of a very annoying constant tinnitus in his right ear.  He advised that his hearing loss has progressed to the point where he currently has difficulty understanding speech, especially if the person speaking is on his right side.  

The VA examiner determined that the Veteran's bilateral hearing loss was less likely than not (less than 50 percent probability) caused by or a result of his active service.  The VA examiner stated that review of the Veteran's military records indicates a history of extensive noise exposure during work, combat, and training conditions.  No changes in pure tone thresholds were detected from test to test.  The first indication of a hearing loss was reported in October 2018.  Based upon review of the Veteran's military records, his report of noise exposure, and the test results, the VA examiner opined that it is more likely than not that the Veteran did not incur the onset of hearing loss while he was in active service, and it is more likely than not that the onset of the Veteran's hearing loss occurred after active service.  The examiner noted that the Veteran reported the onset of his unilateral tinnitus was in the last month and was associated with the significant decrease in hearing in his right ear.  The Veteran denied the presence of any tinnitus prior to that time.  The examiner stated that the cause of the change in his hearing, the onset of his unilateral tinnitus, and the return of his episodes of vertigo are unknown and, therefore, warrant further medical evaluation.

In an April 2019 VA Otolaryngology Outpatient Note, the examiner observed that a March 2019 audiogram showed mild sloping to severe sensorineural hearing loss in the right ear. 

In a March 2020 VA Audiology Note, the Veteran reported decreased hearing since his last evaluation, though the examiner noted that the Veteran's hearing acuity had remained essentially unchanged since the last examination.  

The evidence of record also reflects that the Veteran currently uses hearing aids.

In a January 2021 medical opinion, the VA examiner was asked whether the Veteran's bilateral hearing loss was aggravated beyond its natural progression by his service-connected hole in the right ear drum.  The examiner stated that he could determine a baseline level of severity based on the medical evidence available prior to aggravation or the earliest medical evidence following aggravation by the service-connected hole in the right ear drum.  The VA examiner stated that the evidence shows normal hearing prior to the hole in the ear drum, and the Veteran's hearing was normal in March 1966.  The examiner found that the current severity of the bilateral hearing loss was greater than the baseline.  The VA examiner determined that it was less likely than not that the Veteran's hearing loss was aggravated beyond its natural progression by the service-connected hole in the right ear drum.  The VA examiner explained that the current hearing loss in the right ear is sensorineural in nature, which means it comes from the inner ear.  A hole in the right ear drum (middle ear) will not cause an inner ear hearing problem in the right ear.  Also, concerning the left ear, a physical issue in the right ear (hole in the eardrum) cannot cause an inner ear hearing problem in the opposite (left) ear.  The hole in the right eardrum is not able to aggravate hearing loss in both ears.

The Board notes that, at the April 2019 VA examination, the VA examiner stated that the first indication of a hearing loss was reported in October 2018.   However, the Veteran's VA medical records described above indicate that there was objective evidence of hearing loss going back to at least March 2017.  Also, although the VA examiner noted the Veteran's report that he started noticing hearing loss in service, the examiner did not acknowledge the June 1975 VA examination where the Veteran reported that he had difficulty hearing conversations.  As early as a January 1975 claim for service connection, the Veteran reported ear infection with affected his hearing.  Despite this evidence of hearing loss since active service, the April 2019 VA examiner primarily discussed the hearing loss as a recent development. 

Additionally, the April 2019 VA examiner stated that the Veteran reported the onset of his unilateral tinnitus as having been in the last month and was associated with the significant decrease in hearing in his right ear; and the examiner stated that the Veteran denied the presence of any tinnitus prior to that time.  However, as shown in the records described above, the Veteran reported tinnitus at least as far back as March 2017.  At a July 2018 VA Audiology Note, the Veteran stated that he had experienced intermittent ringing in the right ear for four or five years. 

Thus, the April 2019 VA examiner based her medical opinion on an incomplete and incorrect view of the evidence of record.  

Furthermore, in the January 2021 VA medical opinion, the VA examiner provided an opinion concerning whether the Veteran's claimed bilateral hearing loss was aggravated beyond its natural progression by the Veteran's service-connected hole in the right ear drum.  However, the record does not currently include an opinion concerning whether the Veteran's claimed bilateral hearing loss was proximately due to (caused by) or otherwise a result of the Veteran's service-connected hole in the right ear drum. 

Therefore, the Board finds that remand is necessary to obtain a new VA examination and medical opinion on the etiology of the Veteran's claimed bilateral hearing loss.  The VA examiner must provide an opinion as to whether the Veteran's claimed bilateral hearing loss was caused by, aggravated by, or otherwise related to his active service.  The VA examiner must also provide an opinion as to whether the Veteran's claimed bilateral hearing loss was proximately due to (caused by), aggravated by, or otherwise a result of his service-connected hole in the right ear drum. 

2. Entitlement to service connection for right ear infection

The Veteran contends that he is entitled to service connection for right ear infection.

The Veteran's service treatment records (STRs) are silent for complaints, diagnosis, or treatment of ear problems during active service.  In Reports of Medical Examination from a March 1966 examination and a June 1969 separation examination, the examiners marked the condition of the Veteran's ears and eardrums as normal.  In the Veteran's Reports of Medical History from a March 1966 examination and a June 1969 separation examination, the Veteran reported that he had not experienced ear trouble or running ears.

However, the Veteran has consistently reported that he experienced an ear infection during active service.  

At a VA evaluation in January 1975, the Veteran reported a history of ear infection from 1969, which had reoccurred with headaches and earaches behind the ear. 

In a September 2007 VA Telephone Encounter Note, the Veteran reported that he had ear infections during active service, and his current ear condition felt similar.  He complained of ear pain for the past four days.  He had right ear discomfort with throbbing sounds and pops.  

In a January 2019 private treatment record, the Veteran reported that, while serving in Vietnam during active service, he had one episode of right eardrum rupture and otorrhea (ear drainage).  Ever since then, he has had occasional infrequent right ear infections.  The last ear infection was six months ago.  He used ear drops, which were effective in resolving the right otorrhea six months ago.  For the past five months, he had noticed a decrease in his right ear hearing.  The Veteran also stated that he has difficulty understanding conversations in a noisy environment. 

At an April 2019 VA examination for the Veteran's claimed hearing loss, the Veteran reported that during active service, he suffered a perforated tympanic membrane in his right ear.  He was treated in the field for the injury, but it never really healed.  He stated that, for years, he continued to have problems with ear infections. 

At a November 2019 VA examination for the Veteran's ear conditions, the Veteran reported that, while deployed in Vietnam between 1967 and 1969, he served in the artillery unit as a door gunner on a helicopter.  Every time he flew, his ear popped, and fluid came out.  When he went to medical, they told him it will get better on its own.  When he sought treatment for dizziness and lightheadedness, he discovered that he had an eardrum hole, and there was infection.  His eardrum was patched, and the infection was cleared.  In November 2018, he underwent an operation on the right ear.  The November 2019 VA examiner diagnosed the Veteran with perforated right tympanic membrane status post tympanoplasty.  The VA examiner observed that the Veteran had no residuals as a result of the surgery, and there was evidence of a healed tympanic membrane perforation on the right ear.  

The Board notes that the January 2021 rating decision stated that the Veteran does not show a current diagnosed disability.  However, the Veteran's medical treatment of record shows that the Veteran has experienced and been treated for recurrent intermittent ear infections, including during the period currently on appeal. 

In addition to the medical records described above, in a June 1975 VA examination, the Veteran reported that, in 1968 while flying helicopters in Vietnam, he began having popping in the right ear.  Since that time, shooting pains had occurred in the right ear every month or two.  The Veteran reported some difficulty hearing conversations.  The examiner stated that the ear drums had a dull luster.  The examiner diagnosed the Veteran with chronic bilateral otitis externa (outer ear infection). 

In a September 2007 VA Internal Medicine Attending Note, the Veteran complained of one week of right ear fullness with popping and headache; and the examiner gave an assessment of serous otitis (ear infection). 

In a November 2017 VA Internal Medicine Outpatient Note, the Veteran reported that he had a perforated right tympanic membrane after operating as a gunner in Vietnam.  One month ago, he began noticing increased drainage from the right ear with some mild pain.  The examiner gave an assessment of right ear pain and discharge.  The examiner noted the Veteran's known ruptured tympanic membrane.  The examiner stated that, although the hole appeared to have been closing, the current drainage may indicate that a hole is still present.  The examiner also stated that this may be superimposed otitis externa.

In a December 2017 VA Internal Medicine Attending Note, the Veteran reported mild ear pain.  The examiner observed that the Veteran has very little discharge, and his tympanic membrane was clear; though he had a very small posterior hole in the canal.  The examiner gave an assessment of right otitis externa with questionable otitis media (middle ear infection). 

In a February 2018 VA Physician Emergency Department Note, the examiner noted that a recent ear infection was completely resolved.  In a July 2018 VA Audiology Note, the Veteran reported that he had an ear infection a year and a half ago in the right ear that resolved with prescribed ear drops. 

In a November 2018 Surgery H&P Note, the examiner diagnosed the Veteran with right chronic otitis media with perforation.  The Veteran underwent a right tympanoplasty.  In a January 2019 VA Audiology Note, the Veteran reported improved hearing in the right ear with post-surgical intervention of a right tympanic membrane perforation and infection. 

As shown in the medical records described above, the Veteran has related his right ear infections to his active service and to his service-connected hole in the right ear drum.  However, the evidence of record does not currently include a medical opinion concerning the etiology of the Veteran's recurrent right ear infections. 

Therefore, the Board finds that remand is necessary to obtain a medical opinion on the etiology of the Veteran's claimed right ear infection.  The VA examiner must provide an opinion as to whether the Veteran's claimed right ear infections were caused by, aggravated by, or otherwise related to his active service.  The VA examiner must also provide an opinion as to whether the Veteran's claimed right ear infections were proximately due to (caused by), aggravated by, or otherwise a result of his service-connected hole in the right ear drum. 

Accordingly, the matters are REMANDED for the following actions:

1. Schedule the Veteran for a new VA examination, and have the VA examiner provide a medical opinion to determine the etiology of the Veteran's claimed bilateral hearing loss.  The VA examination should be conducted by a VA examiner who has not previously examined the Veteran.  The claims file must be made available to and reviewed by the examiner in conjunction with the examination.   

After review of the evidence, the examiner should provide the following:

(a) Offer an opinion as to whether it is at least as likely as not that the Veteran's bilateral hearing loss was incurred in, caused by, aggravated by, or otherwise related to his active service.  

In offering such opinion, the VA examiner must consider and address the lay statements of record, including but not limited to the Veteran's reports that he started noticing difficulty hearing during active service.  This should include any reports of decreased hearing during and since active service, including any such reports shown in treatment records from 1975. 

(b) Offer an opinion as to whether it is at least as likely as not that the Veteran's bilateral hearing loss was caused by or a result of his service-connected hole in the right ear drum.

In offering such opinion, the VA examiner must consider and address the lay statements of record, including but not limited to the Veteran's reports that he started noticing difficulty hearing during active service.  This should include any reports of decreased hearing during and since active service, including any such reports shown in treatment records from 1975. 

(c) Offer an opinion as to whether it is at least as likely as not that the Veteran's bilateral hearing loss was aggravated beyond its natural progression by his service-connected hole in the right ear drum. 

In offering such opinion, the VA examiner must consider and address the lay statements of record, including but not limited to the Veteran's reports that he started noticing difficulty hearing during active service.  This should include any reports of decreased hearing during and since active service, including any such reports shown in treatment records from 1975.  

As indicated, in answering these questions, the examiner is asked to consider the statements from the Veteran indicating that symptoms, such as hearing loss, started during service.  The examiner is asked to explain why his statements make it more or less likely that a current hearing impairment started during service.  If indicated, it should be explained whether there is a **medical** reason to believe that the Veteran's recollection of his symptoms during and after service may be inaccurate or not medically supported as the onset or cause of his current diagnosis.  

The examiner should not rely on silence in the medical records unless it can be explained: (a) why the silence in the available records can be taken as proof that the symptom(s) did not occur, including why the fact would have normally been recorded if present, or (b) why the absence of medical records is medically significant.

2. Obtain a medical opinion to determine the etiology of the Veteran's claimed right ear infection.  The VA examination should be conducted by a VA examiner who has not previously examined the Veteran.  The claims file must be made available to and reviewed by the examiner in conjunction with the examination.   

After review of the evidence, the examiner should provide the following:

(a) Offer an opinion as to whether it is at least as likely as not that the Veteran's right ear infections were incurred in, caused by, aggravated by, or otherwise related to his active service.  

In offering such opinion, the VA examiner must consider and address the lay statements of record, including but not limited to the Veteran's reports that he started experiencing ear infections during active service.  This should include any reports of ear infections during and since active service. 

(b) Offer an opinion as to whether it is at least as likely as not that the Veteran's right ear infections were caused by or a result of his service-connected hole in the right ear drum.

In offering such opinion, the VA examiner must consider and address the lay statements of record, including but not limited to the Veteran's reports that he started experiencing ear infections during active service.  This should include any reports of ear infections during and since active service. 

(c) Offer an opinion as to whether it is at least as likely as not (i.e., 50 percent or greater probability) that the Veteran's right ear infections were aggravated beyond their natural progression by his service-connected hole in the right ear drum.  

In offering such opinion, the VA examiner must consider and address the lay statements of record, including but not limited to the Veteran's reports that he started experiencing ear infections during active service.  This should include any reports of ear infections during and since active service. 

As indicated, in answering these questions, the examiner is asked to consider the statements from the Veteran indicating that symptoms, such as ear infections, started during service.  The examiner is asked to explain why his statements make it more or less likely that a current hearing impairment started during service.  If indicated, it should be explained whether there is a **medical** reason to believe that the Veteran's recollection of his symptoms during and after service may be inaccurate or not medically supported as the onset or cause of his current diagnosis.  

(Continued on the next page)

 

The examiner should not rely on silence in the medical records unless it can be explained: (a) why the silence in the available records can be taken as proof that the symptom(s) did not occur, including why the fact would have normally been recorded if present, or (b) why the absence of medical records is medically significant.

 

 

Corey Bosely

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Dawn A. Leung, 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.