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A 64-year-old man with xerostomia and xerophthalmia presented with numbness over the right chin and cheek, progressing over 18 months. He chewed food exclusively on the left side, as he would bite his tongue chewing on the right. On examination, there was multimodality trigeminal sensory loss in the right maxillary (V2) and mandibular (V3) distributions, with weakness and wasting of the right masseter and temporalis muscles (figure 1A). Forehead sensation (V1) and corneal reflex were normal. MR scan of head showed atrophy of all the right-sided muscles of mastication (figure 2); there was abnormal gadolinium enhancement of the right trigeminal nerve, including its maxillary (figure 3A) and mandibular divisions (figure 4). While some enhancement of V2 and V3 is normal, the degree and asymmetry of enhancement was obviously abnormal (figures 3 and 4). The increased enhancement was limited to the nerves themselves, with no appreciable abnormal dural-based enhancement. The serum …
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