After active patient identification, the patient is brought into the operating theater. Carrying out the team time-out. Introductory consultation with the anesthesia department. Induction of anesthesia and intubation of the patient. Positioning of the patient by the surgeon. Transition to PEG insertion. First insertion of the endoscope under visualization and constant air insufflation into the stomach. If the diaphanoscopy is clear, the PEG tube is now placed using the thread pull-through method in the typical manner. Fix the tube in place and apply a wound dressing. Transition to CUP panendoscopy. First position the patient in head reclination. Insert the McIvor oral spatula while protecting the teeth, lips and tongue. Apply the velotractio in the typical manner. Insertion of the Beckmann's ring knife and removal of a flat sample from the epipharyngeal region. In addition, selective removal of smaller samples from the area of Rosenmüller's fossa on both sides. Hemostasis by insertion of an H2O2-soaked ball swab and bipolar coagulation. If the wound bed is dry, the velotractio is removed. Transition to tonsillectomy. Start on the right side. The tonsils appear extremely atrophic. First grasp the upper pole and dislodge the tonsil from the bed. Incision of the mucosa close to the uvula and exposure of the tonsil capsule. Successive dissection along the capsule while protecting the anterior and posterior palatal arch. Exposure of the lower tonsil pole. Bipolar coagulation of the lower pole vessels. Removing the tonsil at the lower pole and performing a mucosal plasty in the direction of the base of the tongue. Insertion of an H2O2-soaked ball swab. Transition to the left side. In principle the same procedure as on the right. Here too, a mucosoplasty is performed on the caudal tonsil pole in the direction of the base of the tongue. Intraoperatively, there was no evidence of malignancy on either the right or the left side. Removal of the McIvor oral spatula. Insertion of the mouth guard. Insertion with the size C small bore tube. First set the base of the tongue in the median line. Take several representative samples from the base of the tongue median and paramedian left and right. The samples are sent separately for histological processing. Hemostasis using monopolar coagulation. Final inspection of the tonsil lobe on both sides. Occasional bipolar coagulation of minor bleeding in the area of the lateral tonsil bed on both sides. If the wound bed is dry, the patient is repositioned for neck dissection. First, skin spray disinfection and infiltration anesthesia. Abjode the surgical site and cover it sterilely. Marking of the mandibular arch and the ascending mandibular branch. Marking of the planned incision. Sharp cutting of the cutis and subcutis. Expose the anterior edge of the sternocleidomastoid muscle. Exposure of the omohyoid muscle. Overall, there is pronounced metastasis, especially in levels II and III. The posterior digastric venter muscle cannot be visualized initially due to the extensive metastatic conglomerate. Therefore turn to visualization of the cervical vascular sheath. Dissection of the internal jugular vein, the venous angle and the common carotid artery, the bifurcation and the internal/external carotid artery. Exposure of the accessorius nerve and successive detachment of the metastatic conglomerate from the digastric muscle. Relocation and, at the end of the operation, re-embedding of the accessorius nerve in the sense of neurolysis. In level II b, the metastases extend far to the cranial side. Successive development of the lateral neck preparation while sparing the accessory nerve and the plexus branches. Clearing of levels II b, II a, III, IV as well as V. Level IV also shows a clearly enlarged lymph node, which however could also be reactively altered by the previous operation. Then turn to the medial neck preparation. Successive detachment of a large metastasis located in the venous angle. Exposure of the hypoglossal nerve and protection of the same. Displacement and, at the end of the operation, re-embedding of the hypoglossal nerve in the sense of neurolysis. Here too, the metastasis extends far to the cranial side. However, the oral branch can be stimulated in depth with the help of stimulation. Ultimately, the medial neck preparation can also be completely developed. At the end of the operation, the wound was dry on all sides. Levels I b, II a, II b, III, IV and V were evacuated. The wound cavity was rinsed with H2O2 and Ringer's solution. Insertion of a 10 Redon drain. Subcutaneous suturing with Vicryl 4.0 and skin suturing with Ethilon 5.0. Application of a wound and pressure dressing. Completion of the operation without complications. Final consultation with the anesthesiologist. The patient received 3 g Unacid intraoperatively as a single shot antibiotic. Conclusion: CUP panendoscopy and right neck dissection in 5 regions. Overall extensive right cervical metastasis. Further procedure after receipt of the definitive histology.