BVA9501176 DOCKET NO. 92-55 765 ) DATE ) RECONSIDERATION ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Whether the rating decision of July 1956, denying service connection for bilateral otitis media, was clearly and unmistakably erroneous. 2. Entitlement to service connection for bilateral hearing loss. 3. Whether new and material evidence has been submitted to reopen a claim for service connection for bilateral otitis externa. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD R. M. Yonemoto, Counsel INTRODUCTION The veteran had active service from February 1952 to February 1956. The veteran's claim for service connection for hearing loss was received in May 1956. A Regional Office (RO) rating action in July 1956 denied service connection for hearing loss, otitis media, and otitis externa. When the notification of the result of the rating decision was sent to the veteran, it was silent as to the hearing loss; he was not informed of the denial of service connection for hearing loss. On January 3, 1966, the Board of Veterans' Appeals (Board) denied service connection for otitis media, otitis externa, and defective hearing. Subsequently, the veteran attempted to reopen the claims for service connection for those disabilities. A reconsideration of the January 3, 1966, decision of the Board was ordered under the authority granted to the Chairman in 38 U.S.C.A. § 7103 (West 1991). Thereafter, the veteran was extended an opportunity to present further arguments to the reconsideration panel. He, however, chose not to submit any additional evidence. The case will now be decided by an enlarged panel of the Board consisting of members who did not review the previous decision of January 3, 1966. The present decision by the enlarged panel will be decided as though the decision of January 1966 had not been rendered. In view of the foregoing, the veteran's claim for service connection for hearing loss has remained open since May 1956 because he was not informed of the denial of that claim in the rating decision of July 1956. The July 1956 rating decision with respect to otitis externa is final, and his attempt in May 1965 to reopen the claim for service connection for that disorder is now on appeal. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that he did not have otitis externa before entering into service and that the ear condition had its inception between the time he was inducted and his arrival and examination at the medical facility at Sampson Air Force Base. It is further maintained that his otitis media did not exist prior to service, that his otitis media originated during service, and that he had the condition continually thereafter. It is also asserted that his bilateral hearing loss unequivocally had its onset in service. It is pointed out that the examiners at the examinations in January and May 1993 commented that the veteran had high frequency hearing loss. 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. Based on a review of the evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the claim for service connection for right ear hearing loss. It is also the decision of the Board that the medical records support the grant of service connection for bilateral otitis media and a left ear hearing loss, and that new and material evidence has been submitted to reopen a claim for service connection for bilateral otitis externa. FINDINGS OF FACT 1. A rating decision in July 1956 denied service connection for otitis media and otitis externa on the basis that these disabilities pre-existed service because they were noted shortly after service entrance and because there was no evidence of any aggravation over and above the natural progress of the disease; the veteran did not appeal that rating decision. 2. Otitis media was not noted at the time of the veteran's service entry, and there is no clear and unmistakable evidence that it pre-existed service. 3. The rating decision of July 1956 with respect to otitis media was completely inconsistent with, and completely unsupported by, the evidence then of record. 4. The evidence at the time of the rating decision of July 1956 unequivocally established that the veteran's chronic bilateral otitis media originated during service. 5. The evidence received since the unappealed rating decision of July 1956 with respect to otitis externa tends to show that the veteran developed chronic otitis externa during service. 6. The current audiological evidence does not demonstrate that the veteran has right ear hearing loss as defined by Department of Veterans Affairs (VA) criteria. 7. The veteran's current left ear hearing loss had its onset in service. CONCLUSIONS OF LAW 1. The unappealed rating decision of July 1956, denying service connection for otitis media, was clearly and unmistakably erroneous based on the evidence then of record. 38 C.F.R. §§ 3.105(a) (1993). 2. The presumption of soundness not having been rebutted, bilateral otitis media was incurred in service. 38 U.S.C.A. § 1110 (West 1991); Veterans Regulation 1(a), Part I, par. I (1943). 3. The unappealed rating decision of July 1956, denying service connection for otitis externa, is final; but new and material evidence has been submitted to reopen a claim for service connection for bilateral otitis externa. 38 U.S.C.A. §§ 1110, 1111, 1131, 5108, 7105 (West 1991); 38 C.F.R. §§ 3.104(a), 3.156(a), 3.303(c) (1993). 4. Right ear hearing loss was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, (West 1991); 38 C.F.R. §§ 3.303(b), 3.385 (1993). 5. Left ear hearing loss was incurred in service. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303(b) (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Initially, the Board finds that the veteran's claims are well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). That is, the Board finds that the claims are plausible. Furthermore, the Board is satisfied that all relevant facts have been properly developed to the extent possible; and there is no further "duty to assist" the claimant, as mandated by § 5107(a). I. Whether the Rating Decision of July 1956, denying Service Connection for Otitis Media, was Clearly and Unmistakably Erroneous. Previous rating decisions, which are final and binding, will be accepted as correct in the absence of clear and unmistakable error. Where evidence establishes such error, the prior decision will be reversed or amended. 38 C.F.R. § 3.105(a) (1993). To establish service connection for a disability, the evidence must show that the disability began in service, or, if pre- existing, that it was aggravated therein. 38 U.S.C.A. §§ 1110, 1131 (West 1991). Every person employed in the active military or naval service shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such active military or naval service. Veterans Regulation 1(a), Part I, par. I (1943). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (1993). FACTUAL BACKGROUND The enlistment examination of the veteran in mid-February 1952 revealed normal ears and drums. In a notification for consultation in connection with service medical processing, dated three days later, it was stated that the veteran reported to the eye, ear, nose, and throat clinic at a service hospital because of "bilateral otitis externa--question of bilateral otitis media," that the examination revealed intact tympanic membranes and much purulent material in the canal, and that the conclusion was bilateral otitis externa existing prior to service. The service medical records from state-side medical facilities disclose that in early February 1954 the veteran complained of ear draining. Examination disclosed that the right eardrum appeared pale, yellow, and wrinkled at the edges. The canal was tortuous. There was also a yellow-white, wrinkled, not especially wet, pinpoint area of white pus. The left drum and canal were similar in appearance as those on the right, but cleaner. A few days later, the ears looked the same, but perhaps with more discharge in the right ear. In mid-February 1954, the impressions were bilateral otitis externa and rule out otitis media. In late February 1954, examination showed that the canals were filled with purulent discharge. The impression was bilateral otitis externa. A few days later, the impressions of bilateral otitis externa and catarrhal otitis media on the right were reported. The service medical records from state-side medical facilities further disclose in mid-March 1954 the veteran was unable to hear from the right ear for 5 to 6 weeks "subsequent to otitis media." Examination showed white exudate in the canals. The impression was chronic otitis externa and media. A few days later, there was still chronic drainage in both ears. On examination, the right eardrum could not be seen because it was covered with thick pus. There was also pus in the left canal, but the tympanic membrane appeared "o.k." The impressions included chronic external otitis. It was noted in late March 1954 that treatment for the bilateral purulent discharge from the ears since February 1954 with antibiotics had not been successful. Examination revealed purulent discharge in both ears. No perforations were seen. The veteran was referred to an ear, nose, and throat clinic. Examination of both tympanic membranes showed no perforations. They were movable. There was some hypertrophy of the skin over the attic of each ear. Foul exudate was found. The impression was bilateral hearing loss coincidental or previous to external infection. The examiner felt that otitis externa was present. In early May 1954, there was no change in the veteran's ear condition. A few days later, it was noted that the ears were dry. The service medical records show that in mid-June 1954 the veteran had debris in the canals. The tympanic membranes looked "o.k." In late July 1954, he sought cleaning of the ears. He was advised, however, not to clean the ears. On an August 1954 ear, nose, and throat examination, the veteran had no complaints. There was ceruminous exudate. Early in the following month, the right ear was clear, but there was yellow ceruminous exudate in the left. In mid-September 1954, slight boggy debris was found in each ear. Both canals were normal in October 1954. In June 1955, the veteran reported having ear problems. There were no complaints, manifestations, or diagnosis of, or treatment for, an ear condition during the remainder of the veteran's service. Separation examination in January 1956 revealed normal ears and drums. On a VA examination in June 1956, the veteran reported having discharge in his ears and ear blockage. Examination revealed scaly canals. They were thickened and abrasive. Discharge was found. The right eardrum was red and thickened. There was discharging. The left eardrum was cloudy, with no landmarks. It was covered with exudate. The diagnoses included otitis media, right, chronic suppurative; and bilateral otitis externa. In a note of May 1965, H. A. McMurray, M.D., related that the veteran was suffering from bilateral mycotic ear disease and that the ear canals were filled with debris which interfered with hearing. At a hearing held before the Board in October 1965, the veteran presented testimony. He stated that prior to his entry into service he did not have any ear condition and that his ear troubles began in Africa during military service. In a note of June 1990, H. W. Brallier, M.D., reported that the veteran was being treated for otitis media and that the disease in both ears was still active and being treated. In July 1991, the veteran appeared at a personal hearing before a hearing officer in the RO. The veteran testified that he had continuously received treatment of his ears since his service discharge, that he had been informed of having perforated and scarred eardrums, and that he had been treated for an ear condition by Drs. Sherman and McMurray. A VA otoscopic examination of the veteran in November 1992 revealed tiny slit-like ear canals. Possible collapsing of the canals was noted. On a VA ear disease examination in January 1993, a detailed history of the veteran's ear condition was reported. Examination revealed that the external auditory canals appeared chronically inflamed with some cerumen, but mostly squamous debris. The inflammation and edema made it very difficult to visualize the tympanic membrane. The tympanic membranes were very thickened and only partly visible because of the external canal edema. There were active disease present and fluid in both external auditory canals. This condition, in the opinion of the examiner, was chronic suppurative otitis media. The impression was chronic bilateral otitis media characterized by intermittent draining of the ears. The examiner also expressed the opinion that the ear condition appeared to have started when the veteran was in Africa. A VA otoscopy in April 1993 showed no excessive cerumen in the veteran's ears. On a VA ear examination in May 1993, a history of the veteran's chronic external otitis and otorrhea which began in 1954 during service was reported. The veteran complained of pain and discomfort due to bilateral ear infections. Examination disclosed chronic hypertrophic external otitis with stenosis of the external auditory canals. The condition, in the opinion of the examiner, resulted from fungal infection beginning in 1954. The examiner stated that there was no evidence of an ear disorder prior to service. The diagnoses were chronic external otitis (hypertrophic) and stenosis of external auditory canals. The veteran had a VA ear examination in July 1993. The external canals were narrow and nontender. No inflammation was noted. The tympanic membranes were clear and mobile. There was no evidence of ear disease. ANALYSIS A rating action in July 1956 denied service connection for otitis media on the basis that the veteran's otitis media pre-existed service because it was noted shortly after service entrance and because there was no evidence of any aggravation over and above the natural progress of the disease. In the same month, the veteran was informed of the denial with respect to the ear condition and advised of his right to appeal. The veteran did not appeal that rating decision of July 1956. The medical evidence before the RO in July 1956 unequivocally disclosed that the veteran did not have otitis media (as distinguished from otitis externa) prior to service. While the RO concluded that the disability pre-existed service because it was noted shortly after his entry into service, the service medical records reveal that the veteran sought treatment for an ear condition, including questionable otitis media, in February 1952, but the examination at that time showed no clinical evidence of otitis media. The Board further observes that there were no clinical findings referable to otitis media on the veteran's service entrance examination. As such, the presumption of soundness at enlistment with regard to the existence of otitis media was for application. Moreover, there were no medical records at the time of the July 1956 rating decision that showed a preservice existence of otitis media. This means that a conclusion of service incurrence of otitis media was mandated because there was no clear and unmistakable evidence that the veteran had otitis media prior to service. In light of the evidentiary record and the legal requirements of 38 U.S.C.A. § 1111 (West 1991), the Board concludes that the July 1956 rating decision was clearly and unmistakably erroneous. A further review of the evidence before the RO in July 1956 disclosed that the veteran was found to have otitis media about two years after he entered service. On several occasions during service, impressions of otitis media were reported. Although the separation examination in early 1956 revealed normal ears and drums, the veteran's drums appeared abnormal in mid-1956, a condition indicative of otitis media. In fact, a diagnosis of otitis media was reported. Under the circumstances, the Board finds that the otitis media in both ears had its onset in service. On this basis, service connection for bilateral otitis media is warranted. Pertinent parts of the veteran's October 1965 and July 1991 testimony are supported by the medical evidence of record. Additionally, a recent VA ear examination showed that the veteran had chronic otitis media, and the examiner at that time expressed the opinion that the veteran's otitis media was related to service. II. Entitlement to Service Connection for Bilateral Hearing Loss. FACTUAL BACKGROUND The enlistment examination of the veteran in February 1952 revealed hearing acuity of 15/15 for whispered voice in each ear. His service medical records disclose that in late February 1954 he complained of inability to hear in the right ear. The impression was catarrhal otitis media with loss of hearing on the right side. A few days later, he still was unable to hear in that ear. In mid-March 1954, it was reported that the veteran had been unable to hear from the right ear for 5 to 6 weeks subsequent to otitis media. The impression was chronic otitis externa and media. It was noted in March 1954 that the veteran had hearing loss in the right ear and that the impression was perceptive-type hearing loss. A service consultation sheet of late March 1954 shows that the veteran had had hearing loss in the right ear since January 1954 when an engine backfired nearby and that the results of tuning fork tests reflected perceptive type hearing loss in the right ear. The impression was that the hearing loss was coincidental or previous to the external infection. In early May 1954, there was no change in the veteran's ear condition. A few days later, it was noted that the ears were dry; but the veteran still complained of hearing loss in the right ear. In early June 1954, the veteran reported that his hearing was not better. On a service audiogram in early June 1954, pure tone air conduction thresholds, in decibels, were as follows: HERTZ 500 1000 2000 4000 RIGHT 20(35) 15(25) 10(20) 20(25) LEFT 30(45) 20(30) 20(30) 20(25) Another audiogram in early June 1954 showed abnormal findings with respect to bone conduction with masking. It should be noted that the figures in parentheses are in ISO standards to facilitate data comparison. Audiometric findings were recorded in ASA standards prior to June 30, 1966, for VA audiometric studies and October 31, 1967, for service audiometric studies. In mid-June 1954, it was reported that the veteran had bizarre mixed deafness as reflected by hearing test. On the separation examination in January 1956, the results of an audiological evaluation were as follows HERTZ 500 1000 2000 3000 4000 RIGHT 75(90) 40(50) 65(75) 65(75) 60(65) LEFT 30(45) 40(50) 45(55) 45(55) 50(55) Hearing acuity for whispered and spoken voice was 10/15 in the right ear and 15/15 in the left. The examiner commented that the veteran had partial and intermittent loss of hearing since 1954 to the current time. On a VA audiological evaluation of the veteran in June 1956, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 30(45) 25(35) 25(35) 35(40) LEFT 20(35) 20(30) 20(30) 30(35) A rating decision of July 1956 denied service connection for loss of hearing on the basis that the veteran's hearing acuity was normal. In a note of May 1965, H. A. McMurray, M.D., related that the veteran was suffering from bilateral mycotic ear disease and that the canals were filled with debris which interfered with hearing acuity. At a hearing held before the Board in October 1965, the veteran presented testimony. He related that his hearing trouble began when he was exposed to an explosion of a backfire from an aircraft engine. In July 1991, the veteran appeared at a personal hearing on appeal conducted in the RO. He testified that he sustained acoustic trauma which caused his hearing impairment, that he was standing fire guard when an aircraft backfired an "knock(ed) his ears out," and that following that incident he could not hear anything. A VA audiological evaluation in November 1992 revealed pure tone air conduction thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 0 25 40 LEFT 10 15 10 55 60 The above results were noted as providing the best estimate of the veteran's organic hearing. He also underwent a VA audiological evaluation, which revealed pure tone bone conduction thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 5 0 25 LEFT 5 10 10 40 The audiologist commented that the right ear exhibited hearing sensitivity essentially within normal limits for pure tones in the lower and middle frequencies up to 3,000 hertz with mild to severe impairment in the higher frequencies and that the left ear exhibited normal sensitivity in the lower and middle frequencies up through 2,000 hertz with moderate to severe mixed impairment in the higher frequencies. Speech recognition in both ears was excellent. On a VA examination in January 1993, the veteran reported feeling as though he had a hearing loss, the left being greater than the right. It was noted that diagnostic testing showed bilateral sensorineural hearing loss in the high frequencies. There was a mild conductive component around 4,000 hertz in both ears. The diagnoses included conductive and sensorineural hearing loss which appeared to have started in Africa. At a VA audiological evaluation in April 1993, the results of the pure tone air conduction testing reflected the best estimate of the veteran's organic hearing. The thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 5 20 20 LEFT 15 20 20 45 40 On a VA audiological evaluation in April 1993, pure tone bone conduction thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 5 20 LEFT 10 10 20 40 The speech recognition ability was 100 percent correct in the right ear and 96 percent correct in the left ear. The audiometric results reflected hearing sensitivity in the right ear to be within normal limits for pure tones. Speech recognition was excellent. On the left, hearing sensitivity in the lower and middle frequencies up through the 2,000 hertz was normal, with mild sensorineural hearing impairment in the higher frequencies. Word discrimination was excellent. During a VA examination in May 1993, the veteran complained of intermittent hearing loss. It was mentioned that an audiogram revealed mild-to-severe high frequency sensorineural hearing loss. In a VA examination worksheet of July 1993, it was reported that diagnostic/clinical test results of the veteran's hearing reflected moderate high frequency sensorineural hearing loss on the left side and normal hearing on the right, that the veteran reported having abnormal hearing on the left for 40 years, and that the diagnosis was chronic sensorineural hearing loss of the left ear. ANALYSIS The Board initially notes that the veteran began having hearing impairment in both ears during service. In fact, the audiological evaluation during his separation examination in January 1956 disclosed bilateral defective hearing. Furthermore, the VA audiogram shortly after his service discharge confirmed the defective hearing. The veteran's testimony at the hearings in October 1965 and July 1991 is consistent with one another and appears credible as regards the facts and events surrounding the right ear defective hearing prior to 1990, but provides no insight into his current hearing acuity. Moreover, the lay assertions regarding his current hearing status do not carry much probative weight in view of the objective and independent medical evidence on file. Regarding the veteran's claim for service connection for hearing loss in the right ear, the Board first points out that there must be evidence of an injury or disease in service and a present disability which is associated with that injury or disease. The medical records show that the veteran had a hearing impairment in the right ear during service and thereafter in the 1950's. Subsequently, his defective hearing in the right ear improved substantially as reflected by the audiometric tests in the 1990's. The results of the air conduction test of hearing in the veteran's right ear in November 1992 appear to be inconsistent with those in April 1993. The Board, however, notes that the November 1992 bone conduction test of the right ear was within normal limits and did not support the findings of an air conduction test at that time. Furthermore, the last VA audiological evaluation, including the air and bone conduction testing, disclosed that his right ear hearing was within normal limits. Because of the findings with respect to the November 1992 bone conduction test and the April 1993 air and bone conduction tests, the Board is of the opinion that the last best estimate of the veteran's organic hearing is controlling, despite the January and May 1993 examiners' opinions of high frequency sensorineural hearing loss. Significantly, an examiner in July 1993 was of the opinion that the veteran had normal hearing in the right ear. The threshold requirement in establishing service connection is that a current disability must be shown to exist. 38 C.F.R. § 3.385 provides that service connection for impaired hearing shall not be established when the thresholds for the frequencies of 500, 1,000, 2,000, 3,000, and 4,000 hertz are all less than 40 decibels; the thresholds for at least three of those frequencies are 25 decibels or less; and speech recognition scores using the Maryland CNC Test are 94 percent or better. The VA pure tone air conduction test in April 1993, which reflected the best estimate of the veteran's organic hearing, showed thresholds of 20 and less for those frequencies. Since the claimed disability is not shown clinically to be present currently as demonstrated by that testing, service connection for right ear hearing loss cannot be established. Under these circumstances, we conclude that service connection for right ear hearing loss is not warranted. Concerning the veteran's claim for service connection for left ear hearing loss, we observe that he first exhibited hearing impairment in the left ear during service. The audiological evaluation of the left ear at the separation examination disclosed hearing loss. Subsequently, the post-service VA audiometric tests in June 1956, November 1992, and April 1993 confirmed that the veteran continuously had a hearing loss in the left ear since service. Hence, after reviewing the evidentiary picture in its entirety, especially the evidence of left ear hearing loss in service and continually thereafter, we are of the opinion that that disability had its onset in service. Service connection for left ear hearing loss is, therefore, warranted. III. Whether New and Material Evidence has been Submitted to Reopen a Claim for Service Connection for Otitis Externa. In a rating decision of July 1956, the RO denied service connection for otitis externa on the basis that that ear condition pre-existed service because it was noted shortly after service entrance and because there was no evidence of any aggravation over and above the natural progress of the disease. In the same month, the veteran was informed of the denial with respect to the ear condition and advised of his right to appeal. He did not appeal that rating decision denying service connection for otitis externa. As such, that decision is final. 38 U.S.C.A. § 7105 (West 1991); 38 C.F.R. § 3.104(a) (1993). When a decision on a claim is final, a veteran may reopen such claim for service connection by the submission of new and material evidence. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.156(a) (1993). The evidence of record at the time of the July 1956 rating decision included the veteran's service medical records and VA examination reports. The evidence submitted since then includes the VA examination report of May 1993. That report shows a history of the veteran's chronic external otitis and otorrhea which began in 1954 during service. Examination disclosed chronic hypertrophic external otitis with stenosis of the external auditory canals. The disability, in the opinion of the examiner, resulted from fungal infection beginning in 1954. He was also of the opinion that there was no evidence of an ear disorder prior to service. The diagnoses were chronic external otitis (hypertrophic) and stenosis of external auditory canals. The examiner's opinion raises a reasonable possibility that the veteran's current bilateral otitis externa originated during his active service from February 1952 to February 1956. The Board, therefore, holds that new and material evidence has been submitted to reopen the veteran's claim for service connection for bilateral otitis externa. Because the claim has been reopened, it must now be reviewed on a de novo basis. Manio v. Derwinski, 1 Vet.App., 140 (1991). ORDER Service connection for bilateral otitis media is granted, based on clear and unmistakable error in a rating action of July 1956. Service connection for left ear hearing loss is granted. Service connection for right ear hearing loss is denied. New and material evidence to reopen a claim for service connection for bilateral otitis externa has been submitted, the appeal is granted to that extent. REMAND Since new and material evidence has been submitted to reopen the veteran's claim for service connection for bilateral otitis externa, certain procedural safeguards must be met before the Board can proceed with a de novo review of that claim. Bernard v. Brown, 4 Vet.App, 384 (1993). The case is, therefore, REMANDED to the RO for the following actions: 1. The RO should schedule the veteran for a VA ear, nose, and throat examination by a board composed of two appropriate specialists to determine the nature and etiology of the bilateral otitis externa. The examinations should be performed in accordance with the Physician's Guide for Disability Evaluation Examinations. All indicated tests and studies should be conducted. The examiners should be requested to provide opinions as to whether the otitis externa pre-existed service, and if so, whether it increased in severity during service beyond natural progression. The veteran's claims folder must be made available to the examiners prior to the examinations to allow for a complete review of the record, particularly the service medical records, to ascertain the history of the disorder in question. 2. Following the above examinations, the RO should review the veteran's claim for service connection for bilateral otitis externa on a de novo basis. If the decision remains adverse to the veteran when the development requested above is completed, the RO should provide an appropriate supplemental statement of the case to the veteran and his representative, giving them ample opportunity to respond. The case should then be returned to the Board for further appellate review. In this REMAND, the Board does not intimate any opinion as to the ultimate determination warranted. No action is required of the veteran until he receives further notice. ________________________ ________________________ GARY L. GICK GEORGE R. SENYK J. U. JOHNSON ________________________ ________________________ BRUCE E. HYMAN DAVID C. SPICKLER NANCY R. ROBIN Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. The remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1993). (CONTINUED ON NEXT PAGE) 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.