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Malignancy (defined as metastatic disease) has been reported in nearly 5% of head and neck paragangliomas. Metastases preferentially target the lymph nodes, lung, liver, or bone. We describe three patients with multiple silent bone metastases exhibiting a fatty halo at MRI that coexisted with expansive bone lesions. In all cases, (123)I-metaiodobenzylguanidine ((123)MIBG) scintigraphy showed no abnormal tracer uptake, whereas (111)In-pentetreotide scintigraphy visualized a few silent bone metastases. These findings indicate that MRI should be included in the staging of paraganglioma patients with risk factors for malignancy.

A 59-year-old man presented with jugular foramen syndrome caused by a mass with roentgenographic and histologic features highly suggestive of a glomus jugulare tumor. However, electron microscopic examination of the surgical specimen revealed features diagnostic of a previously unsuspected renal cell carcinoma. Because primary tumors of the glomus jugulare and metastatic renal cell carcinoma may present with the same clinical and roentgenographic findings and look similar histologically, careful electron microscopic examination of the tumor and urologic screening should be performed in suspected cases of glomus jugulare tumors.