Perineural spread (PNS) is a clinically significant route of tumor extension in head and neck malignancies and is not uncommonly overlooked on imaging. Often clinically occult, PNS may first be suggested by radiologists, and its detection can have significant implications for prognosis and management. This article provides a comprehensive overview of PNS, including relevant cranial nerve anatomy, optimized imaging protocols, and characteristic radiologic features. Multiple illustrative cases are included to improve recognition and highlight the critical role of imaging in the early identification of this often occult disease process.