Citation Nr: 22062806 Decision Date: 11/09/22 Archive Date: 11/09/22 DOCKET NO. 17-13 131 DATE: November 9, 2022 ORDER Service connection for tinnitus as secondary to the service-connected hypertension disability is granted. FINDING OF FACT The evidence is in at least approximate balance as to whether the Veteran's tinnitus is caused by the service-connected hypertension disability, to include antihypertensive medication. CONCLUSION OF LAW The criteria for service connection for tinnitus as secondary to the service-connected hypertension disability are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served in the United States Marine Corps from February 1970 to November 1974. This matter comes to the Board of Veterans' Appeals (Board) on appeal of a February 2015 rating decision from a Department of Veterans Affairs (VA) Regional Office (RO). The issue on appeal was previously remanded by the Board in December 2021 for further development. Service Connection Laws and Analysis Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). An alternative method of establishing the second and third elements above is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a). 38 C.F.R. § 3.303(b). Service connection may also be granted for a disability diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Service connection may also be warranted for a disability aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. Due consideration must be given to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. 38 U.S.C. § 1154; see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Specifically, "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Entitlement to service connection for tinnitus as secondary to service-connected hypertension disability The Veteran maintains that tinnitus was caused or aggravated by the effects of medications prescribed for service-connected hypertension. See Correspondence, September 2014; VA Form 9, February 2017; see also Informal Hearing Presentation, April 2021 ("entitlement to service connection for tinnitus including secondary to hypertension"). The Veteran additionally maintains that tinnitus is related to hazardous noise exposure during active service. See Correspondence, July 11, 2014; see also Notice of Disagreement, April 14, 2015. The Veteran has reported symptoms of tinnitus, including buzzing in the ears. See VA examination, April 2022 (reported "buzzing in both ears"). The Board finds that the Veteran is competent to report symptoms of tinnitus, such as ringing in the ears, as these are symptoms capable of lay observation. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Charles v. Principi, 16 Vet. App. at 374 (veteran is competent to testify as to symptoms of tinnitus experienced during-and-post-service, including ringing of the ears). Accordingly, the Board finds the first element of service connection, a current disability, is met. Several VA medical opinions have been obtained as to whether a nexus or relationship exists between the Veteran's current tinnitus and service-connected hypertension, to include antihypertensive medications. The Veteran underwent a VA examination in January 2015. At that time, the examiner opined that the Veteran's tinnitus was less likely than not caused by or a result of military noise exposure. In this regard, the examiner reasoned that the Veteran's service treatment records reflected audiological testing within normal limits at enlistment and separation, and that no significant decrease in hearing thresholds existed to account for acoustic trauma sustained during active service. Additionally, the examiner noted the Veteran's onset of tinnitus was recent, many years after separation from service. The VA medical opinion provided in January 2015 is afforded no probative weight as the opinion was based on an absence of complaints or diagnosis during service. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). The Veteran was afforded a VA examination in February 2015. At that time, the examiner opined that the Veteran's tinnitus was less likely than not proximately due to or the result of the Veteran's service-connected condition. In this regard, the examiner noted tinnitus is a noise or ringing in the ears and is a common problem that affects approximately one in five people. The examiner noted that tinnitus is not a condition itself, but rather is a symptom of an underlying condition. The examiner noted several underlying conditions known to cause tinnitus, including hearing loss, ear damage or injury, physical injuries, chronic health conditions, and circulatory system disorders. The examiner found that it was less likely than not that the Veteran's antihypertensive medications were a cause of tinnitus as the Veteran's medication regiment was at a suitable dosage, and tinnitus was not a common side effect of any of the Veteran's current medications. The VA medical opinion obtained in February 2015 failed to adequately address the Veteran's lay statements, and as such is afforded little probative value. Notably, however, the February 2015 VA examiner indicated that chronic health conditions and circulatory system disorders could cause tinnitus. Another medical opinion was obtained in April 2022. The examining VA audiologist opined that it was less likely than not that the Veteran's current reported tinnitus was related to service. The VA examiner reasoned that the Veteran's service treatment records did not indicate a significant change in hearing, nor provide evidence acoustic trauma during service. The VA examiner further reasoned that during the January 2015 VA examination, the Veteran reported onset of tinnitus 2 to 3 years prior, 38 years following exposure to noise during service. The examiner further noted that at the time of the April 2022 examination, the Veteran reported tinnitus onset 32 years after separation, beginning in 2006. As to secondary service connection, the April 2022 VA examiner noted the Veteran reported hypertension was diagnosed during service, although the effects of hypertension were beyond the scope of an audiologist's practice and should be addressed by a physician or nurse practitioner. As the April 2022 audiologist disclaimed determinations as to the relationship between tinnitus and hypertension as beyond the scope of practice, the April 2022 audiologist's opinion as to secondary service connection is afforded no probative weight. In August 2022, another VA medical opinion was obtained as to whether the Veteran's current tinnitus was caused or aggravated by the Veteran's service-connected hypertension, to include pharmacological treatments. The VA examiner, an audiologist, opined that it was not within the scope of practice of audiology to determine symptoms of a particular person's hypertension. The VA examiner reasoned that while hypertension and medication may cause tinnitus in some people, it most often does not. The VA examiner further opined that factors considered included onset of hypertension as compared to onset of tinnitus, with onset of tinnitus reported as approximately 2012; occurrence of tinnitus compared to occurrence of episodes of hypertension; amount of medication for hypertension; type of medication; and if records indicated tinnitus was reported in relationship to hypertension. The VA examiner concluded that those factors should be determined by the medical provider that diagnosed hypertension and reiterated that it was not within the scope of practice of audiology to determine symptoms of hypertension for a particular person. As August 2022 audiologist disclaimed determinations as to symptoms of hypertension as outside the scope of practice, the opinion and rationale are afforded no probative weight. Another VA medical opinion was obtained, from a board-certified family nurse practitioner, in August 2022. The examiner stated the Veterans records were thoroughly reviewed and the Veteran's statements regarding tinnitus as secondary to hypertension were considered. The examiner further stated that a review of the medical literature found no aggravating or causal relationship between essential hypertension and tinnitus. Regarding medications, the August 2022 VA examiner stated that the medical literature revealed an association between antihypertensive diuretics and onset of tinnitus. The examiner opined, however, that as a review of the Veteran's medications revealed no antihypertensive diuretic medications, it was less likely than not that the Veteran's hypertension, to include antihypertensive medications, caused or aggravated the Veteran's tinnitus. The VA examiner further noted that the study which found a positive association between hypertension treatments and tinnitus was inconclusive as the authors called for additional research and concluded the Veteran's tinnitus was more likely attributable to age. A review of the competent medical evidence of record reflects that the August 2022 VA examiner's conclusion was based on an inaccurate factual premise. A review of the medical evidence of record shows that the Veteran's hypertensive medications include diuretics such as chlorthalidone. See VA treatment record, August 2022. Chlorthalidone "has a different chemical structure from but the same actions as the thiazide diuretics, used in the treatment of hypertension." See Dorland's Illustrated Medical Dictionary, 341 (33rd ed. 2020). The definition of thiazide diuretics specifically includes compounds that are chemically dissimilar (i.e., a different chemical structure) but act like thiazide diuretics (i.e., diuretic actions) such as chlorthalidone. See Id. at 1888 (33rd ed. 2020) (thiazide diuretics defined as "compounds that cause diuresis...used to treat...hypertension...include[s] compounds that act like thiazide diuretics but are chemically dissimilar"). VA treatment records also explicitly reference treatment of the Veteran's hypertension by antihypertensive diuretics. See e.g., VA treatment note, November 2014 ("picking up a diuretic at WTS today"); September 2018 (blood pressure "is better...due to diuretic"); August 2020 ("[okay] to continue diuretic"). VA medical opinions of record also document the use of diuretic antihypertensives. A VA examiner opined in July 2019 that the Veteran's erectile dysfunction was secondary to service-connected hypertension, to include medication, as erectile dysfunction was common with long term high blood pressure (i.e., hypertension) due to the effects of diuretic antihypertensives. For the reasons above, the Board finds the August 2022 VA medical examiner's rationale sufficiently supports the Veteran's claim. In this regard, the August 2022 VA examiner reasoned that a review of the medical literature revealed a positive association between diuretic hypertensive medications and the development of tinnitus. While the medical literature as cited by the August 2022 VA examiner found that 17 percent of all individuals treated with antihypertensive medications developed tinnitus, a review of the underlying text showed that the "incidence of tinnitus was significantly higher in patients receiving diuretics [27.2 percent]." C. Borghi et al., Prevalence of tinnitus in patients with hypertension and the impact of different antihypertensive drugs on the incidence of tinnitus, Curr. Ther. Res. Clin. Exp. 420-32 (2005). When a medical opinion relies on medical text evidence containing qualifying or contradictory aspects, the issue of whether those aspects of the text diminish the probative value or adequacy of the opinion must be examined. McCray v. Wilkie, 31 Vet. App. 243, 257 (2019). Here, the August 2022 VA examiner reasoned that the study's findings were inconclusive as the authors called for additional research. However, a review of the underlying medical text clarifies that in the "conclusions" section the authors unequivocally concluded that "in patients receiving antihypertensive therapy, tinnitus was found in 17.6 [percent] of patients. Tinnitus was associated with the use of diuretics...Further studies are needed." C. Borghi et al., at 430. That the authors identified areas for further study does not imply invalidation of the conclusions identified in the immediately preceding sentence. Rather, the researchers had previously identified areas of particular interest for future investigation, such as the effects of HMG-CoA reductase inhibitors in patients with tinnitus. A veteran "may invoke an accepted medical treatise in order to establish the required nexus; in an appropriate case it should not be necessary to obtain the services of medical personnel to show how the treatise applies to [the] case." Hensley v. West, 212 F.3d 1255, 1265 (Fed. Cir. 2000). Medical treatise evidence may similarly indicate enough of a basis of a generic relationship to establish a "plausible causality based upon objective facts." Mattern, 12 Vet. App. at 228 (citing Wallin v. West, 11 Vet. App. 509, 514 (1998)). Generally, however, "an attempt to establish a medical nexus...solely by generic information in a medical journal or treatise is too general and inconclusive." Mattern v. West, 12 Vet. App. 222, 228 (1999) (citing Sacks v. West, 11 Vet. App. 314, 317 (1998)). Here, the August 2022 VA examiner introduced medical treatise evidence which establishes a plausible causality between the Veteran's service-connected hypertension to include diuretic antihypertensive medication and currently tinnitus. Further, the medical literature's findings as to the positive association between antihypertensive medications and tinnitus are supported by the VA medical opinions of record. In this regard, the VA medical opinion obtained in February 2015 reasoned that tinnitus is a symptom of an underlying circulatory system disorder and that both chronic health conditions and medications can cause or worsen tinnitus. As discussed above, the Veteran's service-connected hypertension (i.e., a circulatory system disorder and chronic health condition) is treated through the use of antihypertensive diuretics (i.e., medication). Similarly, the August 2022 VA examiner reasoned that a review of the medical literature revealed a positive association between diuretic hypertensive medications and the development of tinnitus. Resolving reasonable doubt in favor of the Veteran, the Board finds the competent medical and lay evidence of record supports a nexus between the Veteran's current tinnitus as caused by service-connected hypertension, to include diuretic antihypertensive medications. As the evidence discussed above is sufficient for finding that all elements of service connection are met, and sufficient for a grant of service connection for tinnitus on a secondary causation basis, the claim for entitlement to service connection on a direct basis will not be addressed. Service connection for tinnitus as caused by service-connected hypertension, to include antihypertensive diuretic medications, is warranted. The appeal is granted. Romina A. Casadei Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Dwyer, William S. The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.