51-Year-Old Man With Tinnitus

51-year-old man with a history of hyperlipidemia presented to the outpatient internal medicine clinic with a 3-week history of tinnitus. He described a “whoosh-whoosh” sound in his right ear that was constant and that increased in intensity with exertion. It was increasing in severity duringtheprevious3weeksandwasassociated with a new-onset, progressive, right-sided headache.Theheadachewasstabbinginnature and occasionally awakened him from sleep. He denied hearing loss, vertigo, vision changes, syncope, and recent illness or trauma. His medications included acetaminophen and naproxen as needed. He had a smoking history of10pack-years,withcessation13yearsbefore presentation; acknowledged drinking 1 to 2 alcoholic beverages per day; denied illicit drug use; and worked as a salesman driving 250 miles per day. On examination, the patient was afebrile, with a blood pressure of 129/82 mm Hg, a pulse rate of 68 beats/min, and a respiratory rate of 18 breaths/min. He appeared comfortable and in no acute distress. He had no scleral injection, and results of funduscopic examination were normal. The external auditory canals and tympanic membranes were visualized and normal bilaterally. Results of Weber and Rinne testing were normal. Cranial nerves II to XII were otherwise intact bilaterally, and the results of the remainder of the neurologic examination were within normal limits. No carotid bruits were auscultated. Heart, lung, abdominal, and lymphatic examination findings were unremarkable.