Esthesioneuroblastoma is a rare malignancy that arises in the olfactory epithelium. We report an interesting case of esthesioneuroblastoma in an 82-year-old man that included an unusual but characteristic imaging feature of this tumor: cysts at the tumor-brain interface. The patient declined primary surgical resection and elected to undergo primary radiation therapy. At 2 years of follow-up, he remained disease-free. The rarity of this tumor and its unique natural history can lead to a complicated assessment of the clinical picture. We review the diagnostic and treatment alternatives.