Firstly, inspection of the oral cavity: insertion of the tonsil plug and inspection of the tonsil region. On the left side, the tonsil is fissured with a small fibroma-like appendage. On the right side, the tonsil shows exophytic changes. A clear induration can be palpated, which extends to the lower tonsil pole. Macroscopically, a T2 tonsillar carcinoma is highly suspected. Then perform an enoral tumor resection: Resection of the tumor including the anterior palatal arch. Successive dissection of the tumorous mass with removal of the pharyngeal muscles; however, the posterior palatal arch can remain intact and is not infiltrated macroscopically or by palpation. Inclusion of the lower tonsil pole and a circumscribed area of the base of the tongue. The preparation is thread-marked for frozen section diagnostics. The fibroma-like appendage of the left tonsil is now removed. Enter with the small bore tube and re-inspect and re-inspect the hypopharynx and larynx. Here, inconspicuous conditions are seen in the region of the base of the tongue, the vallecula and the epiglottis, as well as inconspicuous conditions in the region of the hypopharynx with well-developed piriform sinuses, and the postcricoid region up to the esophageal opening is also clear. Adjustment of the endolarynx. Inconspicuous conditions here as well. The flexible esophagogastroscopy is then performed: easy to see through to the stomach. Inconspicuous conditions in the stomach area. Now, with excellent diaphanoscopy, insertion of a PEG tube. After a problem-free puncture of the stomach using the usual thread pull-through method. Inspection of the esophagus on reflection. Mucosal conditions are visible on all sides, but without any suspicious changes. The frozen section diagnosis now confirms the diagnosis of squamous cell carcinoma. In the area of the medio-caudal marking, higher grade dysplasia is visible, otherwise the frozen section shows an R0 resection. A resection is now performed medio-caudally towards the base of the tongue and the posterior pharyngeal wall, extending to the vallecula. A final marginal sample covering the entire area is sent for frozen section diagnostics and later assessed as tumor-free. After resection, a barely covered, pulsating structure is found at the transition from the oropharynx to the hypopharynx, which could correspond to the internal carotid artery on Doppler sonography, but is otherwise located at the level of the exit of the lingual artery. Decision to explore as part of the neck dissection. In the case of dry enoral conditions, repositioning for neck dissection on both sides: injection with xylocaine and adrenaline. Start with the right side: To do this, make a skin incision by cutting around the previous scar submandibularly. Subcutaneous scarring in the area of the skin incision. Exposure of the sternocleidomastoid after cutting through platysma remnants. A scar block extends into the depths in the area of the previous operation. Dissection of the sternocleidomastoid muscle. Exposure of the accessorius nerve. Then exposure of the omohyoid muscle. Dissection of the omohyoid muscle and exposure up to the hyoid. Exposure of the submandibular gland. Pronounced scarring here too. Exposure of the digastric muscle. Exposure of the facial vein. Exposure of the superior thyroid artery and the hypoglossal nerve and successive removal of the anterior neck preparation. Pronounced scarring in the area of the anterior jugular vein. A clear tumorous mass is palpable caudal to the vein, which is located directly on the internal jugular vein and appears to infiltrate it palpatorily. A tumor cone also grows parallel to the vein cranially below the accessorius level. Further dissection of the vein. Pronounced scarring, but also clear evidence of tumor infiltration, so that the decision is made to resect the vein. Caudal exposure of the vein. Exposure of the common carotid artery and the vagus nerve. Removal of the vein after ligation and repositioning and cranial dissection. The mass infiltrates a few plexus branches. These are also resected. Now continue to expose the common carotid artery. Identification of the exit of the superior thyroid artery. Identification of the external and internal carotid artery. Cranial to the exit of the superior thyroid artery, a very strong vessel branches off and runs directly towards the resection area. Trace and visualize this vessel. In terms of caliber and localization, this vessel corresponds to the one seen enorally and is then removed after ligation and repositioning. Now successive dissection of the lymph node metastasis cranially. Cranial removal of the vein, also after ligation and repositioning. The accessor nerve can be spared. If there is significant scarring, there is infiltration of the tumor. Circumscribed with the sternocleidomastoid muscle, this is partially resected. The accessorius triangle has already been resected. Level Vb is now removed while carefully preserving the supraclavicular vessels. Final inspection and, if the wound is dry, insertion of a 10 Redon drain and careful two-layer wound closure and turning to the opposite side: skin incision. Cut through subcutaneous tissue. Exposure of the platysma. Dissection of the platysma and creation of a platysmal flap. Exposure of the external jugular vein and the auricular nerve. These are spared (as on the opposite side). Exposure of the sternocleidomastoid muscle. Dissection and exposure of the accessorius nerve. Exposure and free preparation of the omohyoid muscle up to the hyoid. Exposure of the submandibular gland. Completing the dissection towards the hyoid. Exposure of the facial vein and preservation of the vein. Expose the digastric muscle posteriorly. Now successively expose the anterior neck preparation. Expose the superior thyroid artery and the hypoglossal nerve as well as the cervical artery. Preservation of the structures. Further exposure of the facial vein and free preparation of the internal jugular vein. Cranial preparation. It can now be seen that the nervus accessorius runs behind the vein on this side. Careful protection. Clearing of the accessorius triangle and completion of level Va. If the wound is dry, irrigation of the wound and two-layer wound closure after insertion of a 10-gauge Redon drain. Now re-inspect enorally. Finally, meticulous hemostasis. The previously identified vessel can no longer be visualized by inspection and Doppler sonography. Now mucosal adaptation in the area of the vallecula and hypopharynx and, after final inspection, completion of the procedure. On the way to the recovery room, the patient can now be aspirated with fresh blood. In addition, saturation is only 90% with oxygen supply, so the patient is taken back to the operating room and reintubated. Re-inspection. A discrete, diffuse, venous hemorrhage is found, which is treated by meticulous hemostasis. Finally, absolutely dry wound conditions. Due to urgent indication by <CLINICIAN_NAME> and anesthesia, the patient is now tracheostomized. Repositioning of the patient. After infiltration anesthesia with xylocaine and the addition of adrenaline, a sparing, horizontal skin incision is made below the cricoid cartilage. Cut through the subcutaneous tissue. Exposure of the prelaryngeal musculature. Exposure of the cricoid cartilage. Exposure of the anterior surface of the trachea. An extremely thin thyroid isthmus is visible. This is bipolarly coagulated and severed. Further exposure of the anterior surface of the trachea and insertion between the 2nd and 3rd tracheal ring. Performing a mucocutaneous anastomosis and subsequent problem-free reintubation to an 8-gauge tracheoflex cannula. Conclusion: At least cT2 cN2b oropharyngeal carcinoma on the right. Performance of a modified radical neck dissection on the right with resection of the internal jugular vein and partial resection of the sternocleidomastoid muscle. The patient should remain fasting for at least 3 to 5 days. After this, a diet should be started, initially with liquid food. Rapid decannulation should be aimed for. If possible, the first cannula should not be changed before the 4th postoperative day. Staging should also be supplemented during the further inpatient course. Due to the extent of the tumor, adjuvant therapy is certainly indicated.