Citation Nr: 0001507 Decision Date: 01/19/00 Archive Date: 01/28/00 DOCKET NO. 94-26 821 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office and Insurance Center, in St. Paul, Minnesota THE ISSUES 1. Entitlement to service connection for right ear hearing loss with otitis media of the right ear, mastoiditis and perforation of the tympanic membrane. 2. Entitlement to an increased evaluation for left ear hearing loss, currently evaluated as 10 percent disabling. 3. Entitlement to a compensable evaluation for otitis media of the left ear. 4. Entitlement to a compensable evaluation for a left ear mastoidectomy scar. ATTORNEY FOR THE BOARD D. J. Drucker, Associate Counsel INTRODUCTION The veteran had active military service from March 1953 to March 1955. This matter comes to the Board of Veterans' Appeals (Board) on appeal from 1993 and 1994 rating decisions of the Department of Veterans Affairs (VA) Regional Office and Insurance Center (RO & IC) in St. Paul, Minnesota. In June 1996, the Board found that new and material evidence had been submitted and reopened and remanded the veteran's claim of entitlement to service connection for right ear hearing loss. The Board also found that his claims of entitlement to service connection for right ear otitis media with mastoiditis and perforation of the tympanic membrane and an increased evaluation for left ear hearing loss was inextricably intertwined with the issue of service connection for right ear hearing loss and remanded those claims to the RO & IC. In May 1998, the Board found that new and material evidence had been submitted to reopen the veteran's claim for entitlement to service connection for right ear otitis media with mastoiditis and perforation of the tympanic membrane. It remanded the veteran's claims to the RO & IC for further evidentiary development. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable determination of the veteran's claims has been obtained by the RO & IC. 2. Right ear hearing loss was not present in service or manifested within one year thereafter, and any current right ear hearing loss is not shown to be related to service or any incident of service, including a service- related disability. 3. Any pre-existing right ear otitis media, mastoiditis and perforation of the tympanic membrane did not worsen in service and any current right ear otitis media, mastoiditis and perforation of the tympanic membrane is not shown to be related to active service, or any incident thereof. 4. A VA audiologic examination in September 1998 showed pure tone thresholds in four frequencies from 1,000 to 4,000 Hertz that averaged 99 decibels in the veteran's service- connected left ear with a speech recognition of 24 percent that corresponds to Level XI hearing. 5. Left ear otitis media is not manifested by drainage or active infectious disease of either the inner or outer ear and has not been shown to be an active, suppurative process. 6. A depressed area posterior to the left external ear manifests the veteran's service-connected left ear mastoidectomy scar; the area is well healed and nontender. CONCLUSIONS OF LAW 1. Right ear hearing loss with otitis media of the right ear, mastoiditis and perforation of the tympanic membrane was not incurred in, or aggravated by, service. or due to service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 1153, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.306, 3.310, 3.383, 3.385 (1999). 2. The criteria for an increased evaluation for left ear hearing loss are not met. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. §§ 4.85, 4.87, Diagnostic Codes 6100-6110 (effective prior to June 10, 1999); 38 C.F.R. §§ 4.85-4.87, Diagnostic Code 6100 (effective June 10, 1999). 3. The criteria for a compensable evaluation for left ear otitis media are not met. 38 U.S.C.A. §§1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.87a, Diagnostic Code 6200 (effective prior to June 10, 1999); 38 C.F.R. §§ 4.85- 4.87, Diagnostic Code 6200 (effective June 10, 1999). 4. The criteria for a compensable evaluation for a left ear mastoidectomy scar are not met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.31, 4.118, Diagnostic Codes 7800, 7803, 7804, 7805 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran is seeking service connection for right ear hearing loss, otitis media, mastoiditis and perforation of the tympanic membrane. The veteran's claim is well grounded within the meaning of 38 U.S.C.A. § 5107(a). That is, he has presented a claim that is plausible. Further, the veteran's claims for increased and compensable evaluations for left ear hearing loss, otitis media and a mastoidectomy scar are plausible and capable of substantiation and, thus, well grounded within the meaning of 38 U.S.C.A. § 5107(a); see Proscelle v. Derwinski, 2 Vet. App. 629 (1992) (a claim of entitlement to an increased evaluation of a service-connected disability generally is a well-grounded claim). When a veteran submits a well-grounded claim, VA must assist him in developing facts pertinent to that claim. 38 U.S.C.A. § 5107(a). The Board is satisfied that all relevant evidence has been obtained regarding the veteran's claims and, to that end, it remanded his case in June 1996 and May 1998 to afford the veteran the opportunity for further VA examination. The examination reports are associated with the claims folder and no further assistance to the veteran with respect to these claims is required to comply with 38 U.S.C.A. § 5107(a). The Board notes that a March 1987 Social Security Administration (SSA) award certificate indicates that the veteran was considered to be totally disabled and entitled to disability benefits as of October 1986. The nature of the veteran's disabling condition(s) was not described; however, he did not allege that records pertinent to the issues on appeal were in the possession of SSA, nor did he request the Board to remand the case for the purpose of obtaining SSA records. Therefore, the Board has determined that a remand for the purpose of obtaining SSA records is not warranted. In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41 (1999) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed the veteran's service medical records and all other evidence of record pertaining to the history of his service- connected left ear hearing loss, otitis media and mastoidectomy scar and has found nothing in the historical record that would lead to a conclusion that the current evidence of record is inadequate for rating purposes. In addition, it is the judgment of the Board that this case presents no evidentiary considerations that would warrant an exposition of the remote clinical histories and findings pertaining to the disability at issue. I. Factual Background When the veteran was examined for induction into service in January 1953, pertinent right ear complaints or findings were not shown. No right ear abnormalities were described. His hearing was 15/15, bilaterally, for the whispered voice test. Service medical records dated in 1954 show that the veteran was repeatedly treated for left ear problems. A February 1954 radiographic report described both mastoids as sclerotic with more sclerosis on the left side and almost no pneumatization on the right side. The conclusion was sclerotic mastoids, bilaterally, that indicated chronic mastoiditis. According to an early July 1954 clinical record, the veteran gave a history of left eardrum perforation when he was seven years old that caused continual discharge. On examination, his right tympanic membrane was normal, while the left was perforated. A later dated July 1954 clinical record reflects that gave a history of recurrent attacks of otitis media since childhood, usually in his left ear. Sclerosis of the right tympanic membrane was noted on a physical examination report. Complaints and diagnoses were not referable to a right ear abnormality. According to a record entry the next day, an audiogram showed hearing within average limits on the right. An August 1954 radiographic report also described bilateral sclerotic mastoiditis with no positive evidence of cholesteatoma. In September 1954, the veteran underwent a left radical mastoidectomy and thereafter developed an infection of the left external auditory canal that was treated conservatively. When examined in March 1955, prior to discharge, there was no report of right ear abnormality. The veteran's hearing was 15 in the right ear and 0 in the left ear on the spoken and whispered voice tests. The veteran's service records show that his most significant duty assignment in service was an anti-aircraft artillery battalion. Post service, a June 1955 statement from F. Fellows, M.D., reflects no right ear abnormality. A June 1955 VA examination report is not referable to complaints or diagnoses of a right ear disorder. Audiogram findings, in pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 10 5 In a July 1955 rating action, service connection was granted for left ear otitis media, suppurative, with a mastoidectomy scar and hearing loss. In its decision, the RO & IC noted that the evidence documented the veteran had chronic suppurative otitis media prior to service that was evaluated as 10 percent disabling, and the resulting 10 percent rating was based on aggravation. A March 1967 VA examination report reflects findings of right ear tympanic scarring and otitis media. Audiogram findings, in pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 5 20 40 Right ear speech discrimination was normal. In its March 1967 rating decision, the RO & IC noted that recent VA examination showed a normal right ear and an improved left ear condition. The left ear was considered improved because of the absence of his preservice disability, but the veteran's 10 percent disability (hearing loss) continued. An October 1977 statement from J.H. Leek, M.D., indicates that the veteran had a large hole in the right eardrum and was diagnosed with chronic suppurative otitis media in the right ear. In an October 1979 statement, Dr. Leek diagnosed chronic suppurative otitis media, right ear. A November 1979 VA examination report reflects the veteran's complaints of bilateral hearing loss. Central perforation of the right ear with chronic inflammatory changes was noted. Audiogram findings, in pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 45 45 65 5 Speech reception was 86 percent in the veteran's right ear. A slight decrease in hearing was noted since he was examined in 1977. A February 1983 private audiogram appears to reflect findings, in pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 60 55 75 75 A May 1983 VA Ear, Nose and Throat (ENT) consultation report indicates that the veteran had a large perforation in the right tympanic membrane and reported drainage from that ear approximately once a week. Central perforation of the right tympanic membrane was noted. Audiogram findings, in pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 5 0 5 In January 1984, VA hospitalized the veteran and he underwent a modified radical mastoidectomy of the right ear. The record indicates that he did well postoperatively. VA outpatient records dated in March 1984 reflect decreased sensorineural hearing loss. VA hospitalized the veteran in May 1984 for treatment of persistent right ear drainage. His ear was surgically cleaned, but a graft was found unnecessary. VA outpatient records dated in June 1984 show the veteran continued to complain of right ear drainage. In an August 1984 statement, the veteran said the results of his recent right ear surgery were disastrous. His hearing had decreased and that affected his ability to work and to drive because he could not hear emergency sirens or car horns. A September 1984 VA outpatient record shows both of the veteran's mastoid bowls were moist. A November 1984 VA examination report includes the veteran's report of right ear drainage. He was unable to understand ordinary conversation and experienced recurrent ear infections that he treated with eardrops. The examiner noted the veteran's history of left ear drainage and mastoidectomy in service and right ear drainage after discharge followed by tympanomastoid in 1983 (1984). A small amount of clear drainage on the right, with a clear cavity was observed. On the left, the cavity was dry. Audiogram findings, in pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 55 65 60 85 The assessment was moderately profound bilateral sensorineural hearing loss. A July 1986 VA examination report reflects the veteran's complaints of total deafness following ear surgery. The veteran told the ENT examiner that right ear drainage began approximately four years earlier, followed by the modified radical tympanomastoidectomy on the right in 1984. The veteran wore a hearing aid in his right ear despite recurrent ear discharge. Examination revealed bilateral mastoid cavities with purulent exudate. The left ear had possible cholesteatoma material. Audiogram findings, in pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 55 60 60 85 The audiogram report indicates that drainage was visible in both ears. The audiometric data was consistent with data obtained in November 1984 that revealed a moderate to severe sensorineural hearing loss in the right ear and a severe to profound mixed hearing loss in the left ear. Speech discrimination was impaired, bilaterally. The veteran was to expected to have difficulty understanding conversation in most listening situations. Private medical records, dated from October 1991 to January 1994, reflect the veteran's complaints of bilateral hearing loss with drainage, more on the right. In February 1993, minimal drainage was observed on the right and considerable left ear drainage with some granulation superiorly on the right was reported. A February 1993 private audiogram appears to reflect findings, in pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 85 90 80 75 90 LEFT 95 100 85 110 110 The private physician said audiometrics revealed a severe neurosensory hearing loss, bilaterally, with fairly good discrimination on the right at 80 percent and on the left at 60 percent. A new hearing aid was recommended. When seen in September 193, the veteran's ears were clean and dry and he wore a right ear hearing aid. The impression was chronic mastoid disease, bilaterally, that was stable but resulted in poor hearing. In September 1993, the RO received the veteran's claim for an increased rating for his service-connected left ear disability. In a February 1994 statement, the veteran said he had a bilateral ear infection in service and underwent left ear surgery. Soon after discharge, he said he began going deaf in his left ear. Approximately ten years ago, the veteran said his right ear hearing deteriorated due to the infection that required surgery and did not improve his hearing. In a June 1994 affidavit, the veteran said he was exposed to acoustic trauma during basic training in 1953. The veteran described an incident in which a tank stopped directly over the foxhole that he was in, the driver raced the motor that caused the noise to reverberate in the foxhole and the sound was so loud he suffered a severe headache after the training exercise. However, the veteran did not report the injury or seek medical attention. He believed that his bilateral hearing loss was at least partially due to acoustic trauma in service. In a June 1994 statement, Todd J. Freeman, M.D., an otolaryngologist, said he examined the veteran once in September 1993 regarding hearing and chronic ear disease. Dr. Freeman said the veteran's audiogram revealed substantial bilateral mixed hearing losses with depressed speech reception thresholds consistent with his pure tone audiograms. The veteran's history of bilateral mastoidectomies was noted, with one procedure performed in service and the other approximately ten years earlier. Dr. Freeman said the veteran noted one episode of acoustic trauma in service and had difficulties with otitis externa. The specialist was unable to opine as to what portion of the veteran's hearing loss was attributed to acoustic trauma suffered in training, but said it would account for the multiple compounding factors responsible for his hearing loss. Further the veteran's mastoid surgery was not a result of the external ear infections he suffered in service. Dr. Freeman stated that chronic mastoiditis and cholesteatoma resulted primarily from chronic middle ear infections and cholesteatoma resulted primarily from chronic middle ear infections and Eustachian tube dysfunction. This was most likely something the veteran was predisposed to regardless of any external ear infections in service. The mixed hearing loss noted on an audiogram meant there was an underlying nerve type of hearing loss and difficulty conducting sound from the air into his inner ear. The conductive portion of his hearing loss resulted when the mastoidectomy was performed because usually a portion of the ear drum and the chain of hearing ossicles behind the eardrum needed to be removed at the time of surgery to help control the disease process, if the disease process did not already destroy them. Dr. Freeman said the veteran's hearing loss was multifactorial. In the specialist's opinion, a portion of the veteran's sensorineural component of his hearing loss resulted from noise trauma suffered during service but the external ear infections in service did not cause the chronic mastoid disease. An August 1994 VA audiologic examination report reflects the veteran's complaints of decreased bilateral hearing and occasional dizziness. He wore a right ear hearing aid. The assessment was bilateral mixed hearing loss, worse on the left. Audiogram findings, in pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 80 75 90 80 90 LEFT 105 95 95 105+ 105+ The pure tone threshold average in the veteran's right ear was 84 decibels and in his left ear was 100+ decibels. Speech recognition scores on the Maryland CNC word lists were 54 percent in the veteran's right ear and 0 percent in his left ear. Test results showed severe apparently mixed hearing loss in the right ear and profound mixed loss in the left ear with poor speech discrimination in the right ear. In November 1996, the veteran, who was 70 years old, underwent VA ENT examination and gave a one-month history of dizziness with disequilibrium and unsteadiness, that was improving. On examination of the right ear, there was a post incision scar, the mastoid wall was down and cavity clean. The left ear showed wall up mastoidectomy with a bulging tympanic membrane and no otorrhea currently. Diagnoses included chronic bilateral otomastoiditis, status post bilateral tympanomastoid and questionable active disease in the left ear. Resulting vertigo and disequilibrium of unknown etiology was also diagnosed, possibly due to BPU (blood pressure vertigo?)/ labyrinthitis or otomastoiditis/cholesteatoma (left). Audiogram findings, in pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 90 85 75 70 80 LEFT 105+ 100(m) 90 105 105+ The pure tone threshold average in the veteran's right ear was 78 decibels and in his left ear was 100+ decibels. Speech recognition scores on the Maryland CNC word lists were 74 percent in the veteran's right ear and 6 percent in his left ear. Test results revealed right ear moderately severe/profound, possibly mixed hearing loss, with moderately impaired speech. In the left ear, severe/profound mixed hearing loss with very poor speech recognition was reported. In a December 1996 memorandum, the VA Chief of the Otolaryngology Section at a VA medical center responded to the RO & IC's request for an opinion regarding whether the veteran's right ear hearing loss was related to active service. The VA otolaryngologist said the veteran had recurrent ear infections pre service and when recruited in March 1953 had active left chronic otitis media that was treated with a tympanomastoidectomy. No active right ear disease was noted at the time. However, the VA physician said mastoid x-rays from that period showed mastoid sclerosis on the right ear and such findings were indicative of bilateral oto-mastoidititis. However, right ear hearing remained normal at the time. The doctor noted that during service, no right ear problems were described and there were no records to suggest that right ear hearing deteriorated during service. Post service, the veteran developed right ear problems that ultimately resulted in hearing loss and mastoid surgery. It was the VA otolaryngologist's opinion that it was more likely than not that the veteran's right ear hearing loss was not related to active military service. In September 1998, the veteran underwent VA audiologic examination and gave a history of serving as a communications technician in Panama during service. According to the VA examination report, the examiner said the nature and etiology of the veteran's left ear hearing loss was due most probably to the otitis media that necessitated the tympanomastoidectomy. While mastoid sclerosis in the right ear was noted in service, the VA examiner commented that there was no indication for surgical intervention in the right ear during active service. The doctor said that at the time of the veteran's left ear surgery in service, his right ear was most likely affected by otomastoiditis as well. The nature of the veteran's otomastoiditis in both ears was most likely a result of chronic Eustachian tube dysfunction that was incurable. According to the VA doctor, the veteran probably had bilateral ear difficulty as a child. On examination, the veteran's external auricle and external auditory canal and cavity were well formed without granulation tissue or evidence of excessive debris. The tympanic membranes were intact, bilaterally. There was minimal evidence of landmarks as far as middle ear structures were concerned. In the VA specialist's opinion, the nature and etiology of the veteran's hearing loss were related to chronic Eustachian tube dysfunction that led to chronic otitis media that led to chronic otomastoiditis and resulted in the need for bilateral mastoid surgeries. Audiogram findings, in pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 85 85 75 75 80 LEFT NR 100 90 105 100 The pure tone threshold average in the veteran's right ear was 79 decibels and in his left ear was 99 decibels. Speech recognition scores on the Maryland CNC word lists were 80 percent in the veteran's right ear and 24 percent in his left ear. The veteran gave a history of extensive noise exposure in service and, post service, service, in a steel mill and construction. Test results showed severe to profound probably mixed hearing loss in the right ear and profound mixed loss, across all frequencies, in the left ear. Speech understanding was mildly impaired on the right and very poor on the left. In a January 1999 Addendum, the VA Chief of Otolaryngology who provided the RO & IC with the December 1996 special opinion, responded to a request for additional information. The VA specialist noted the veteran's childhood recurrent ear infections and that he was recruited to service in 1953 and developed otitis media in the left ear. No right ear problems were described in service, although the specialist observed that imaging study showed a sclerotic right ear, so one could assume that the pathology was present during service as well. The doctor said that the veteran developed ear (right, apparently) problems after discharge and there was no documentation that the veteran's right ear problems worsened in service. In the VA specialist's opinion, the veteran's right ear hearing loss and problem were most likely linked to a baseline problem of Eustachian tube dysfunction and the recurrent childhood ear infections. The VA otolaryngologist concluded that veteran's current right ear hearing loss and pathology was not related to the service- connected left ear hearing loss and pathology. According to the physician, it was possible to have chronic otitis media in one ear and have no problems in the other. In the veteran's case, the doctor observed that the veteran had recurrent otitis media during childhood in both ears that resulted in sclerotic mastoids and, most likely was related to poor Eustachian tube function and, thereafter, developed bilateral ear trouble. However, the left ear process was unrelated to the right ear process. They were two separate diseases that could occur independently. The veteran's right ear pathology was not related to his left ear pathology. The VA specialist said he reviewed the veteran's claims folder and his own December 1996 opinion and his opinion remained unchanged that it was more likely than not that the veteran's hearing loss and problem in the right ear were unrelated to service. In April 1999, the veteran underwent VA dermatologic examination. The examiner noted that there was no visible specific scar associated with a depression behind the veteran's left ear. The depressed area was posterior and external to the ear, was 5 centimeters (cm.) from the superior to inferior edge, 3 cm. from the anterior to posterior edge and was deepest at the interior end where is was about 1 cm. deep. The area was well healed and non- tender. The diagnoses included a depressed area posterior to the left external ear that was consistent in appearance with the site of a prior mastoidectomy. The area was well healed and nontender. II. Analysis A. Service Connection for Right Ear Hearing Loss with Otitis Media, Mastoiditis and Perforation of the Tympanic Membrane. According to 38 U.S.C.A. §§ 1110 and 1131, a veteran is entitled to disability compensation for disability resulting from personal injury or disease incurred in or aggravated by service. "A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service." Watson v. Brown, 4 Vet. App. 309, 314 (1993). Even if there is no record of organic disease of the nervous system (e.g., sensorineural hearing loss) in service, its incurrence coincident with service will be presumed if it was manifest to a compensable degree within one year after service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.307, 3.309 (1999). While the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree. Id. 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). For the purpose of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Even though disabling hearing loss may not be demonstrated at separation, a veteran may, nevertheless, establish service connection for a current hearing disability by submitting evidence that the current disability is related to service. Hensley v. Brown, 5 Vet. App. 155 (1993). The threshold for normal hearing is from 0 to 20 decibels and higher threshold levels indicate some degree of hearing loss. See Hensley (citing Current Medical Diagnosis & Treatment, Stephen A. Schroeder, et. al. eds., at 110-11 (1988)). See also 38 C.F.R. § 3.385. The veteran has contended that service connection should be granted for right ear hearing loss with otitis media, mastoiditis and perforation of the tympanic membrane. However, when examined for induction into service in March 1953, a right ear abnormality was not reported and his hearing was normal. While he was treated for left ear problems in service and x-rays showed sclerotic mastoids, service medical records are completely negative for complaints, diagnosis or treatment of right ear hearing loss or ear disease. When examined for separation in March 1955, the veteran's right ear hearing was normal and a right ear abnormality was not found. Although a VA examiner in March 1967 described right tympanic membrane scarring, it was not until 1977, more than twenty ears after the veteran's discharge from service, that a large hole in his right eardrum was reported and chronic suppurative otitis media in the right ear was diagnosed. Further, it was not until November 1979, nearly twenty-four years after discharge, that right ear hearing loss was reported. The medical evidence also indicates that in 1986 the veteran told a VA examiner that his right ear drainage began approximately four years earlier, that was many years after service discharge. More importantly, the Board observes that two VA otolaryngologists, who reviewed the veteran's entire medical record, concluded that right ear hearing loss, otitis media, mastoiditis and perforation of the tympanic membrane were unrelated to his period of active service. In December 1996, the VA Chief of Otolaryngology opined that even though x-rays in service showed mastoid sclerosis of the right ear, findings indicative of bilateral otomastoiditis, right ear hearing was normal and no right ear problems were described in service nor were there records to suggest that right ear hearing deteriorated in service. The VA otolaryngologist opined that it was more likely than not that right ear hearing loss was unrelated to active service. In September 1998, a VA ENT specialist, who examined the veteran, opined that the veteran's chronic Eustachian tube dysfunction in childhood led to chronic otitis media that led to chronic otomastoiditis and resulted in the need for bilateral mastoid surgeries. Moreover, in January 1999, the VA otolaryngologist who provided the December 1996 opinion reviewed the veteran's claims files again and said his opinion remained unchanged. While x-rays showed a sclerotic right ear in service, the veteran developed right ear problems after discharge and there were no medical records to document right ear problems that worsened in service. The VA physician opined that the veteran's right ear hearing loss and problems were most likely linked to a baseline problem of Eustachian tube dysfunction and the recurrent ear infections during childhood. While the medical evidence documents that the veteran had right ear mastoid sclerosis in service, that may be indicative of otomastoiditis, right ear hearing was normal in service, no right ear problems were described and there are no clinical records to document that any pre-existing right ear pathology worsened in service. See 38 C.F.R. § 3.306. Certainly, a disability that is proximately due to or the result of a service-connected disease or injury may be service connected. 38 C.F.R. § 3.310(a). See Allen v. Brown, 7 Vet. App. 439, 448 (1995). However, the veteran has presented no competent medical evidence to show any etiological relationship-including on the basis of aggravation-between his right ear hearing loss, mastoiditis and tympanic membrane perforation on the one hand, and his service-connected left ear hearing loss, otitis media and mastoidectomy scar on the other. See Heuer v. Brown, 7 Vet. App. 379 (1995) (There was no medical evidence of any nexus between current right-ear hearing loss and any disease or injury incurred during service.). Further, January 1999, the VA Chief of Otolaryngology said that the veteran's current right ear hearing loss and pathology was not related to the service-connected left ear hearing loss and pathology. The doctor noted that the left ear process was unrelated to the right ear process and they were two separate diseases that could occur independently. In support of his contentions, the veteran points to Dr. Freeman's June 1994 report. While the conclusions of a physician are medical conclusions that the Board cannot ignore or disregard, see Willis v. Derwinski, 1 Vet. App. 66 (1991), the Board is free to assess medical evidence and is not compelled to accept a physician's opinion. See Wilson v. Derwinski, 2 Vet. App. 614 (1992). Although on an initial review, Dr. Freeman's statement appears to support the veteran's claim, a close reading shows that it does not. Dr. Freeman examined the veteran on only one occasion and did not review the veteran's claims folder and service medical records. His opinion is both equivocal and speculative and, at most, does little more than propose that a portion of the veteran's mixed right ear hearing loss was caused by acoustic trauma in service, but said external ear infections in service did not cause the chronic mastoid disease. He does not factually establish or explain the sequence of medical causation using the facts applicable in the veteran's case. Such speculation is not legally sufficient to establish service connection. See Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). In fact, Dr. Freeman also found that the veteran's mastoid surgery was not a result of ear infections in service, but attributed the chronic mastoiditis and cholesteatoma to chronic middle ear infections and Eustachian tube dysfunction. Furthermore, the veteran reported just one incident of acoustic trauma, during basic training in 1953, but in 1998 told a VA examiner (but not Dr. Freeman) that he was exposed to acoustic trauma in steel mills and construction after discharge. In his written statements, the veteran has repeatedly attributed his right ear hearing loss and pathology to service. In 1994, he variously asserted that he had a bilateral ear infection in service that caused his post- service right ear hearing loss and other pathology and that he was exposed to acoustic trauma in service. Nevertheless, the veteran is not qualified as a lay person to furnish etiological opinions or medical diagnoses, as this requires medical expertise. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494-495 (1992). Accordingly, the Board finds that a preponderance of the evidence is against the veteran's claim of entitlement to service connection for right ear hearing loss, otitis media, mastoiditis and perforation of the tympanic membrane. Service connection for right ear hearing loss, otitis media, mastoiditis and perforation of the tympanic membrane must, therefore, be denied. 38 U.S.C.A. §§ 1110, 1131, 1153; 38 C.F.R. §§ 3.303, 3.304, 3.306, 3.310, 3.385. The evidence is not so evenly balanced that there is doubt as to any material issue. 38 U.S.C.A. § 5107. B. Increased Evaluations In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41 (1999) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed the veteran's service medical records and all other evidence of record pertaining to the history of his service- connected left hearing loss, otitis media and mastoidectomy scar and has found nothing in the historical record that would lead to a conclusion that the current evidence of record is inadequate for rating purposes. In addition, it is the judgment of the Board that this case presents no evidentiary considerations that would warrant an exposition of the remote clinical histories and findings pertaining to the disability at issue. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R. Part 4 (1999). The Board attempts to determine the extent to which the veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (1999). When entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). 1. Left Ear Hearing Loss The veteran's statements regarding the effect that the service-connected left ear hearing loss has had on his life have been noted. In evaluating service-connected hearing impairment, however, disability ratings are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Effective June 10, 1999, certain regulatory changes were made to the criteria for evaluating audiological disabilities. See 64 Fed. Reg. 25202-25210 (1999) codified at 38 C.F.R. §§ 4.85-4.87 (1999). Generally, when the laws or regulations change while a case is pending, the version most favorable to the claimant applies, absent congressional intent to the contrary. Karnas v. Derwinski, 1 Vet. App. 312-13 (1991). But see Rhodan v. West, 12 Vet. App. 55, 57 (1998). The Board observes that summary information accompanying the regulatory changes to the rating criteria for evaluating audiological disabilities specifically indicates that, except for certain "unusual patterns of hearing impairment", the regulatory changes do not constitute liberalizing provisions. 38 C.F.R. § 4.86. The "unusual patterns of hearing impairment" include cases where the pure tone thresholds at each of the four specified frequencies (1,000, 2,000, 3,000 and 4,000 Hertz) is 55 decibels or more, or where the pure tone thresholds are 30 decibels or less at 1,000 Hertz and 70 decibels or more at 2,000 Hertz. While the veteran's left ear hearing loss pattern fits the requirements of an unusual pattern of hearing impairment, with pure tone thresholds at each of the four specified frequencies at 55 decibels or more, the Board finds that its action on the veteran's claim at this time will not result in any prejudice to him even though the agency of original jurisdiction (here the RO & IC) had not yet had an opportunity to apply these regulatory changes to the veteran's claim. See generally Bernard v. Brown, 4 Vet. App. 384 (1994). Evaluations of unilateral defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests together with the average hearing threshold level as measured by pure tone audiometry testing in the frequencies 1,000, 2,000, 3,000 and 4,000 Hertz per second. The rating schedule establishes eleven different auditory acuity levels designated from Level I for essentially normal auditory acuity to Level XI for profound deafness. 38 C.F.R. §§ 4.85, 4.87, Diagnostic Codes 6100- 6110 (effective prior to June 10, 1999) and 38 C.F.R. §§ 4.85, 4.87, Diagnostic Code 6100 (effective June 10, 1999). In situations where service connection has been granted for defective hearing involving one ear, and the veteran does not have total deafness in both ears, a maximum 10 percent evaluation is assignable where hearing in the service-connected ear is at level X or XI. See 38 C.F.R. §§ 3.383, 3.385, 4.85, 4.87, 4.87, Table VII, Diagnostic Codes 6100, 6101 (prior to June 10, 1999) and 38 C.F.R. §§ 4.85-4.87, Diagnostic Code 6100 (effective June 10, 1999). The November 1996 VA audiometric findings revealed a left ear pure tone threshold average of 100+ decibels with a speech recognition score of 6 percent. Under the old and new regulations, these findings are consistent with a Level XI hearing in the service-connected left ear. Findings obtained at the time of the September 1998 VA examination showed pure tone air conduction threshold average, in decibels, for the veteran's left ear was 99 decibels with speech recognition ability of 24 percent. These findings are consistent with Level XI hearing in the service-connected left ear under the old and new regulations. Inasmuch as service connection is currently in effect only for defective hearing in the left ear, and the veteran is not totally deaf in both ears only the findings pertaining to that ear are considered in evaluating service-connected hearing loss disability. See 38 C.F.R. §§ 3.383, 4.14 (1999). Level XI hearing in the service-connected left ear corresponds to the 10 percent evaluation under Diagnostic Code 6100. Accordingly, the Board concludes that a higher evaluation for the veteran's service-connected left ear hearing loss is not shown to be warranted under the rating criteria in effect prior to June 10, 1999 and the criteria effective on June 10, 1999. In reaching its determination, the Board observes that the changes between the schedular criteria effective prior to June 10, 1999 and the revised criteria, effective June 10, 1999, are relatively minor and the Board does not find that its application of both sets of criteria in this decision will result in prejudice to the veteran even though the RO & IC had not evaluated the veteran's disabilities under the new criteria. See generally Bernard v. Brown, 4 Vet. App. 384 (1994). In this case, both the old and new regulations would yield the assignment of a 10 percent disability rating for the service-connected left ear hearing loss by means of a mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluation. Id. 2. Otitis Media of the Left Ear. The veteran's service-connected otitis media is rated under 38 C.F.R. § 4.87a Diagnostic Codes 6200 and 6201 (effective prior to June 10, 1999) and 38 C.F.R. § 4.87, Diagnostic Codes 6200 and 6201 (effective June 10, 1999). A 10 percent disability rating is warranted for otitis media during the suppurative process. Id. When, as is the case with the veteran, the otitis media is not in the suppurative state, it is rated on the basis of loss of hearing. Id. As noted above, in this case, the veteran's service-connected left ear hearing loss has already been rated separately. The provisions of 38 C.F.R. § 4.87a, Diagnostic Code 6200 (and 38 C.F.R. § 4.87, Diagnostic Code 6200) specifically indicate that the veteran shall receive a 10 percent rating for chronic, suppurative otitis media during the continuance of the supurative process. As there is no current evidence of left ear otitis media recurrences, the provisions of 38 C.F.R. § 4.87a, Diagnostic Code 6200 (and 38 C.F.R. § 4.87, Diagnostic Code 6200) are not for application. The preponderance of the evidence is against a compensable evaluation for left ear otitis media. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 4.87a, Diagnostic Codes 6200, 6201 (prior to June 10, 1999) and 38 C.F.R. § 4.87, Diagnostic Codes 6200, 6201 (effective June 10, 1999). Moreover, the evidence is not so evenly balanced as to allow for the application of reasonable doubt. 38 U.S.C.A. § 5107(b). 3. Left Ear Mastoidectomy Scar. The RO has rated the veteran's left ear mastoidectomy scar under Diagnostic Code 7800. 38 C.F.R. § 4.118, Diagnostic Code 7800. Scars of the head, face or neck warrant a noncompensable evaluation if they are slightly disfiguring or a 10 percent evaluation if they are moderately disfiguring. Id. Alternatively, a 10 percent evaluation may be assigned for superficial scars that are poorly nourished with repeated ulcerations. 38 C.F.R. § 4.118, Diagnostic Code 7803. A 10 percent evaluation is also warranted for superficial scars that are tender and painful on objective demonstration. 38 C.F.R. § 4.118, Diagnostic Code 7804. A scar may also be rated based on the limitation of function of the part affected. 38 C.F.R. § 4.118, Diagnostic Code 7805 (1998). The medical evidence on file reveals that, in fact, there is no visible specific scar associated with a depression behind the veteran's left ear. The depressed area is well healed with no objective signs of tenderness, or indications that it was poorly nourished or ulcerated. Further, there is no evidence of record suggesting that this area is productive of any functional restriction. While the area displayed depression there was no report of inflammation. Further, there was no ulceration and the scar was not painful. Again, there was no limitation of function noted. On VA examination in 1999 there was no indication that the left ear depressed area is demonstrative of any associated impairment or disability. Also, there is no indication of any nerve involvement. The recent VA dermatologic examination findings, in the Board's opinion, do not demonstrate that the left ear scar is disfiguring. Since there is no clinical or other probative evidence of record indicating that the veteran's scar is disfiguring, poorly nourished, ulcerated, painful or tender, or that it is productive of any functional limitation, the Board finds that there is no basis for the assignment of a compensable rating for the left ear mastoidectomy scar. 38 U.S.C.A. § 1155, 5107; 38 C.F.R. § 4.118, Diagnostic Code 7800. Further, the veteran's disability does not more nearly approximate the criteria for a compensable evaluation. Moreover, the evidence is not so evenly balanced as to allow for the application of reasonable doubt. 38 U.S.C.A. § 5107(b). ORDER Service connection is denied for right ear hearing loss, otitis media, mastoiditis and perforation of the tympanic membrane. An increased evaluation is denied for left ear hearing loss. A compensable evaluation is denied for left ear otitis media. A compensable evaluation is denied for a left ear mastoidectomy scar. ROBERT E. SULLIVAN Member, Board of Veterans' Appeals