BVA9505306 DOCKET NO. 93-08 336 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES Entitlement to service connection for defective hearing in the left ear; bilateral otitis media; status post right mastoidectomy; postoperative myringotomy and tympanoplasty; and bilateral tinnitus. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Joseph P. Gervasio, Jr., Counsel INTRODUCTION The veteran served on active duty from February 1976 to December 1981 and from November 1990 to August 1991. This case comes to the Board of Veterans' Appeals (Board) on appeal of an April 1992 rating decision of the St. Louis, Missouri, Regional Office (RO) of the Department of Veterans Affairs (VA), which denied service connection for bilateral hearing loss, bilateral otitis media, status post mastoidectomies and tympanoplasties, and tinnitus. Service connection for hearing loss in the right ear was granted by the RO in February 1993. Service connection for left ear hearing loss was denied by the RO in a February 1982 rating decision. A petition to reopen the claim was denied by the RO in a November 1986. Since that time, the veteran has had an additional period of active duty. The Board considers the claim reopened by evidence shown in the last period of service and will review it on a de novo basis. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that service connection should be established for hearing loss in the left ear, bilateral otitis media, and tinnitus. He asserts that, although he had an ear disorder prior to service, it was only "swimmers ear" which caused him little difficulty, and it was only after he had been on active duty for several months that he developed a severe ear condition that eventually required surgery. He asserts that he did not have tinnitus before service, but first developed the condition after his right ear surgery in 1979. The representative points out that when the veteran was called to active service in the Persian Gulf, in 1990, he was given an H-2 profile for hearing loss, but when he finished his tour of duty, in 1991, his profile had increased to H-4. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file(s). Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence supports the claims for service connection for hearing loss in the left ear, otitis media, status post mastoidectomy, tympanoplasty, and myringotomy, and bilateral tinnitus. FINDINGS OF FACT 1. Hearing loss of the left ear pre-existed service and chronically increased in severity therein. 2. Otitis media pre-existed the veteran's service and increased in severity therein. 3. Mastoidectomies, tympanoplasties, and a myringotomy were surgical procedures undergone in service which meant to ameliorate the auricular condition, but the auricular difficulties were otherwise chronically worsened by service. 4. Tinnitus had its onset during the veteran's first period of service. CONCLUSION OF LAW 1 A pre-existing left ear disorder and hearing loss of the left ear were aggravated by service. 38 U.S.C.A. §§ 1110, 1131(West 1991); 38 C.F.R. § 3.303(1994). 2. A pre-existing right ear disorder was aggravated by service. 38 U.S.C.A. § 1131(West 1991); 38 C.F.R. § 3.303(1994). 3. Tinnitus was incurred during service. 38 U.S.C.A. § 1131(West 1991); 38 C.F.R. § 3.303(1994). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Factual Background The veteran served on active duty from February 1976 to December 1981 and from November 1990 to August 1991. On examination for entry upon active duty, in February 1976, the veteran did not report having ear trouble or hearing loss. Clinical evaluation of his ears and eardrums was normal. Audiometric evaluation showed air conduction threshold levels in the left ear as follows: HERTZ 500 1000 2000 3000 4000 LEFT 30 20 10 25 60 Service medical records show that the veteran underwent two audiometric evaluations on the same day in June 1976. These tests showed air conduction threshold levels in the left ear as follows: First Test HERTZ 500 1000 2000 4000 6000 LEFT 40 45 40 100 100 Second Test HERTZ 500 1000 2000 4000 6000 LEFT 25 45 30 75 85 It was remarked that the veteran had an appointment at the ear, nose and throat clinic (ENT) in August 1976. In August 1976, the veteran was evaluated at the ENT clinic. It was reported that he had had inner ear infections and scarring since early childhood and had an "H-2" profile on entering service. He complained of intermittent tinnitus, occasional vertigo, and intermittent drainage from the right ear. A large cholesteatoma was noted on the right. A retracted area of the attic was noted on the left. An audiogram was interpreted as showing bilateral moderate to severe hearing loss, mixed on the right, with a 20 decibel air-bone gap and a sensorineural hearing loss of 50 decibels on the left. The impressions were severe bilateral ear disease, with a cholesteatoma and moderate-severe mixed hearing loss on the right, and moderate-severe sensorineural hearing loss on the left. On follow-up evaluation at the ENT clinic in August 1976, it was recommended that the veteran be placed on an H-4 profile unless his hearing could be corrected by a hearing aid. He was sent to the audiology clinic, where additional testing was conducted. It was interpreted as showing mild to moderate mixed hearing loss, bilaterally, that was not suggestive of the severity initially indicated. Amplification was not recommended at that time. The veteran was allowed to return to duty, provided he wore ear protection. He was to be closely monitored. The veteran was again treated in June 1977 for his bilateral hearing problem. Examination disclosed a questionable cholesteatoma and a perforation on the right. The left ear was normal. He reportedly had been told that he needed surgery on the right. The assessment was severe bilateral hearing loss. In October 1977, the veteran complained of right ear pain of 3 days' duration. His left tympanic membrane was scarred and somewhat retracted. His right tympanic membrane showed purulent exudate and canal inflammation. The pertinent assessments were otitis externa and questionable otitis interna. In July 1978, the veteran presented with a long history of bilateral mixed hearing loss, with a cholesteatoma on the left. Physical examination showed an attic cholesteatoma on the right. Surgery was recommended. X-ray studies of both mastoids, in September 1978, showed some sclerosis, bilaterally, involving the mastoids indicating chronic mastoiditis. There was no definite evidence of cholesteatoma formation. The veteran was hospitalized in April 1979. It was reported that he had a ten plus year history of drainage and pain in his right ear. He had been followed for a long time for a cholesteatoma that had eroded the posterior wall. He also had a hearing loss in the right ear and occasional dizziness. He underwent a right tympano-mastoidectomy and a tympanoplasty and had a totally benign postoperative course. He was discharged from the hospital in May 1979. The diagnosis was cholesteatoma, right ear, in antrum, mastoid. Service medical records show that the veteran was seen on several other occasions for complaints of ear disability. In March 1980, mucous was noted in the ear. The ear was cleaned. In June 1981, he was noted to have mild to severe mixed hearing loss in the right ear, with fair speech discrimination, and severe high frequency hearing loss in the left ear, with excellent speech discrimination. The assessment was to determine suitability for fitting with amplification in the right ear. In July 1981, it was noted that the veteran had undergone a modified radical mastoidectomy in May 1979 and had had a great deal of draining and intermittent running since that time. The examiner believed a revision in the right ear was necessary, but indicated that it could not be performed before the veteran was discharged from service in three weeks. On examination for separation from service, in July 1981, examination of the right tympanic membrane showed decreased acuity of landmarks. The left tympanic membrane showed scarring and was retracted. An audiometric examination showed air conduction thresholds in the left ear as follows: HERTZ 500 1000 2000 3000 4000 6000 LEFT 35 45 35 45 85 NR In early August 1981, it was noted that the ear was draining less. No cholesteatoma was seen. The veteran seemed to be doing well. The assessment was status post Brody mastoidectomy. The veteran was evaluated for National Guard service in December 1983. Audiometric examination showed air conduction threshold levels in the left ear as follows: HERTZ 500 1000 2000 3000 4000 6000 8000 LEFT 20 5 5 5 5 10 30 Medical records of C. Edward Felker, III, M.D., show that the veteran was hospitalized in August 1984 for an elective tympanomastoid on the right. The veteran underwent a right middle ear exploration with placement of ventilation tube. During surgery, it was noted that the eardrum was adhered to the incus. The diagnosis was chronic otitis. Two audiological evaluations, dated in July and August 1984, were included with the report. The July study showed the following air conduction threshold levels in the left ear: HERTZ 250 500 1000 2000 3000 4000 8000 LEFT 30 30 30 20 25 85 90+ Similar findings were shown on the study performed in August 1984. A letter from Christopher H. Jung, M.D., dated in September 1986, shows that he had treated the veteran in November 1985 for hearing loss that had progressively grown worst. Examination disclosed a right radical mastoidectomy with a tube in place, with a small granuloma adjacent to the tube and pus draining through the tube. The left ear appeared clear. He performed a septoplasty in December 1985 because he believed the Eustachian tube problems were related to septal deviation. When last examined, in January 1986, significant improvement was shown. An audiometric study showed a moderately severe mixed conductive neurosensory loss in the right ear with a moderate neurosensory loss, primarily in the left ear, with severe high frequency component in both ears. The hearing loss was considered to be consistent with the veteran's history of ear infections and previous surgery, as well as the history of service-related noise exposure. A copy of an August 1985 audiogram accompanied the statement. A letter, dated in October 1991, and medical records, dated from October 1990 to March 1992, have been received from David M. Lewis, M.D. They show that, in October 1990, the veteran was treated for his "life long history of Eustachian tube dysfunction." Examination revealed 30 to 40 percent perforation of the right tympanic membrane, with ongoing otitis media and externa and adhesive otitis media on the left side, with obvious destruction of some of the ossicles and destruction of the sputum in the attic. One week later, it was noted that the veteran had drainage and infection in the right ear, as well as obvious Eustachian tube dysfunction in the left ear. He needed surgery for a cholesteatoma in the left ear, but the infection in his right ear needed to resolve first. An examination was performed for entrance into active duty in November 1990. At that time, air conduction threshold levels in the left ear were as follows: HERTZ 500 1000 2000 4000 8000 LEFT 15 10 15 50 >50 Service medical records from the veteran's second period of service show that he was treated in February 1991 for an acute infection drainage of the right ear with intermittent light- headedness. He was given medication and placed on light duty. In March 1991, the veteran was hospitalized at a military medical facility for a chief complaint of drainage from his right ear. He had been air evacuated from Riyadh, Saudi Arabia, and had had six weeks of drainage from his right ear and disequilibrium with hearing loss. It was reported that he had had chronic right otitis media since the age of 12. His surgical history included a radical mastoidectomy on the right side in 1978 and right tympanoplasty reconstruction in 1984. He was transferred to another facility, where examination of the left ear showed a significant central retraction with no cholesteatoma and no evidence of any residual fluid. Examination of the right ear showed poor ear drum mobility and a well-healed mastoid cavity with a slight mucosal band scar in the middle of the remaining tympanic membrane remnant. He had an anterior perforation that was significantly inflamed and thickened in this region. In June 1991, he underwent a revision of a tympanomastoidectomy on the right side and a left myringotomy with PE tube on the left side. The diagnoses were chronic left adhesive otitis media and right chronic mastoiditis. An audiological examination was performed by VA in October 1991. Air conduction threshold levels in the left ear were as follows: Hert z 250 500 1000 1500 2000 3000 4000 6000 8000 Left 50 35 20 35 30 35 90 105 100 At 500 hertz, tinnitus was found at 75 decibels in the right ear and at 35 decibels in the left ear. The audiologist reported that the veteran had first noticed tinnitus after ear surgery in 1979. It was now a bilateral condition. An ENT examination was performed by VA in November 1991. The veteran's medical history included ear infections dating back to about 1976. He also had chronic otitis in the right ear, associated with cholesteatoma, and had undergone a right tympanomastoidectomy in May 1979. He reported doing reasonably well for a few years, but developed recurrent problems and underwent a revision of the right tympanomastoidectomy in June 1991. At that time, he had left serous otitis and underwent placement of a left air ventilation tube. He complained of decreased hearing and constant tinnitus dating back to the 1970's and mild intermittent dizziness dating back to January 1991, when he descended on a plane on his way to Saudi Arabia. The diagnoses were status post chronic otitis in the right ear, dating back to the 1970's, treated with a right tympanomastoidectomy in 1979, with revision in 1991; status post left myringotomy tube placement in June 1991; bilateral neurosensory hearing loss and conductive hearing loss in the right ear dating back to 1979 and 1991 in the left ear; and constant tinnitus. A hearing was conducted at the RO in January 1993. The veteran testified that, while he had had a right ear disorder prior to entering service in 1976, it was not a serious illness. Rather, it was described as "swimmers ear," manifested by moisture in the ear and an earache. He said that he was not treated for a right ear disability until he had been on active duty for some time and had been transferred to Germany. He noted that he had not had any significant problems with his left ear until he service in Saudi Arabia in 1991. II. Analysis The veteran's claims are well-grounded; that is, they are not inherently implausible. 38 U.S.C.A. § 5107(a). The facts relevant to the issues on appeal have been properly developed, and the statutory obligation of VA to assist him in the development of his claim has been satisfied. Id. In order to establish service connection for a claimed disability, the facts, as shown by the evidence, must demonstrate that a particular disease or injury resulting in current disability was incurred during active service or, if preexisting active service, was aggravated therein. 38 U.S.C.A. §§ 1110, 1131. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). A preexisting injury or disease will be considered to have been aggravated by active service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A § 1153; 38 C.F.R. § 3.306(a). Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the preservice disability underwent an increase in severity during wartime service. This includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. 38 U.S.C.A § 1153; 38 C.F.R. § 3.306(b). A. Hearing Loss in the Left Ear The audiometric reports show that when the veteran first entered service, in February 1976, his hearing acuity in his left ear was impaired, particularly at 4,000 hertz. He correctly points out that such was noted on his physical profile. (The threshold for normal hearing is from 0 to 20 decibels. Higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet.App. 155, 157 (1993)). Looking at the audiometric findings before, during, and after service, it is clear that chronic deterioration of his hearing acuity in his left ear has occurred. For example, while he initially presented with a 60-decibel loss in 1976, hearing acuity now is at the 90-decibel loss level. Findings in service confirm a steady deterioration, representing an increase in disability. There is no specific finding in this record which shows that his increased disability was due to the natural progression of his hearing condition, nor is there any clear and unmistakable evidence in this record that rebuts the presumption of aggravation of his preservice hearing condition. Hence, a grant of service connection for hearing loss in the left ear is warranted. B. Otitis Media A veteran who served during a period of war or during peacetime service after December 31, 1946, is presumed in sound condition except for defects noted when examined and accepted for service. Clear and unmistakable evidence that the disability manifested in service existed before service will rebut the presumption. 38 U.S.C.A § 1111, 1137. At the time the veteran entered active duty in 1976, clinical examination of the ear showed no abnormality. Therefore, he is presumed to have been in sound condition in this respect at that time. Thereafter, however, he presented with auricular complaints of drainage, dating them back to his childhood years. Admissions while giving a clinical history constitute clear and unmistakable evidence that is sufficient to rebut the presumption of soundness. Doran v. Brown, 6 Vet.App. 283 (1994). Therefore, the Board finds that the disorders preexisted his first period of service. It may be argued that his inservice problems only represented the natural progress of his preservice condition. However, that argument fails because there is a specific finding made by the service department that his condition was aggravated by his service environment--his service during Desert Storm in Saudi Arabia. This is strong evidence in support of the claim, and it is not refuted. The veteran's testimony is consistent and credible, and based on the evidence presented, a grant of service connection for bilateral otitis media is warranted. C. Mastoidectomies, Myringotomies, Tympanoplasties After the veteran began to experience recurring auricular problems in service, it became clear that conservative medical treatment would not abate the condition. Surgical intervention was required. Some might argue that the surgeries were remedial in nature and thus had the effect of ameliorating the conditions, not aggravating them. On the other hand, specific evidence in this file shows that his auricular disorders were aggravated by service. This evidence cannot be overlooked or ignored. It is not counterbalanced by probative evidence against the claim. Consequently, service connection for the foregoing surgical procedures is warranted. D. Tinnitus The veteran first complained of tinnitus during his first period of active duty. He testified that the condition had its onset following surgery on his right ear in service. He has been service-connected for hearing loss which has a sensori-neural component. Generally, manifestations of tinnitus are not dissociated from the sensorineural component of mixed hearing loss where there has been evidence of damage to the cochlea. See e.g., 2 Cecil's Textbook of Medicine, § 462, at 2119-20 (18th ed. 1988). Hence, the evidence supports a grant of service connection for bilateral tinnitus. ORDER Service connection for hearing loss in the left ear, bilateral otitis media, status post mastoidectomy, tympanoplasty, myringotomies, and bilateral tinnitus is granted. M. CHEEK Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.