Anesthesia is first induced by the anesthesia colleague. A rigid tracheobronchoscopy is then performed by the 1st surgeon. There is no evidence of a secondary tumor in the area of the glottis, subglottis and trachea up to the entrance of the main bronchi. Intubation by the surgeon and head positioning. Next, a flexible gastroscopy is performed. The flexible gastroscope is advanced into the stomach under constant air insufflation. Inspection of the stomach reveals non-irritable mucosal conditions with a very pronounced small gastric curvature. After inspection of all areas of the stomach, the esophagus is thoroughly examined from caudal to cranial with the flexible gastroscope. Linea serrata inconspicuous at 42 cm from the upper alveolar ridge. The caudal middle and cranial part of the esophagus is completely clinically unremarkable. Removal of the flexible gastroscope and insertion of the size B small bore tube. The oral cavity and oropharynx are inspected. In the area of the glossotonsillar groove on the left edge of the tongue, a small ulcer of at least 1-1.5 cm in diameter is seen, which is relatively coarse on palpation and grows into the tongue muscles. Other areas of the oropharynx such as the base of the tongue, vallecula, both tonsils, posterior pharyngeal wall and lateral pharyngeal wall are completely unremarkable. A biopsy is then taken from the ulcers described above and the tissue is sent for frozen section examination. A direct pharyngoscopy and inspection of the supraglottis using a size C Kleinsasser tube is also performed. The hypopharynx (piriform sinus on both sides and retrocricodal area) and supraglottis showed normal anatomical conditions with no evidence of a secondary malignancy. Removal of the size C small siphon tube without injury to the oral structures. After waiting for the frozen section diagnosis, a histology in the sense of a squamous cell carcinoma is confirmed. Next, a PEG is placed with classic sutures. The next step is to resect the tumor on the left edge of the tongue. Here, a distance of 1 to 1.2 cm from the ulcer is made clinically as well as a relatively deep excision in the tongue musculature. The specimen is then thread-marked. In addition, a sample is taken from the tumor bed; a strip is cut from the tongue musculature and sent separately for histological analysis. Careful hemostasis using bipolar forceps. No evidence of injury to the great vessels in the sense of the lingual artery. The patient is then repositioned for neck dissection and left parotidectomy. Skin disinfection. Application of 4 electrodes for monitoring the facial nerve. Infiltration of the subcutis using 10 ml mixed solution of Suprarenin and Ultracaine. Sterile washing and covering. Insertion of a skin incision from the jugulum to the mastoid on the left. Dissection in depth and sharp cutting of the subcutis and platysma. At the cranial edge of the incision, a portion of the skin above the parotid gland, where a coarse needle biopsy was performed, is included in the preparation. Next, lift off the subplatysmal flap anteriorly and cranially as well as laterally and posteriorly. Identification of the external jugular vein and auricular nerve. Both structures enter the mass cranially so that both structures are ligated and separated approx. 5 cm from the caudal metastasis. Then identify the superficial cervical fascia and further dissect from lateral to medial. Dissection is then carried out in the level IV area, where a complete clearing of level IV is performed. During the dissection, the artery and transverse vein of the neck are exposed and spared, but a branch of the thoracic duct is exposed and injured. Intraoperatively, intrathoracic pressure is then increased and the open vessel is found and then additionally ligated. Further control with artificial Valsalva shows no evidence of lymphorrhea. Then successive dissection from caudal to cranial with sparing of the cervical plexus. Further dissection from caudal to cranial until the large metastasis is identified in level IIa, IIb and the cranial part of level V. This metastasis is at least 6 cm in diameter and is obviously growing into the sternocleidomastoid muscle and internal jugular vein as well as the caudal parotid region. After clearing level III, level I is then cleared successively from caudal and anterior to cranial and posterior, sparing the submandibular gland. Cranially, the ramus marginalis mandibulae is exposed and completely spared. Dissection practically up to the caudal area level IIa, here complete adhesion of the internal jugular vein as well as the accessorius nerve and sternocleidomastoid muscle can be seen. Next, a partial parotidectomy is performed under facial nerve monitoring from cranial and anterior to posterior and caudal. A distance of at least 1-2 cm is maintained from the large parotid metastasis. After dissection at the anterior parotid margin, the ramus marginalis mandibulae and a pronounced buccal branch are visualized. These are now followed in a retrograde course under constant facial stimulation. Successive dissection from the periphery to the center until the cervicofacial ramus and then the facial nerve are identified. The facial nerve and its branches, although relatively close to the mass, are not fused with the mass. The main cords of the facial nerve are carefully and completely exposed here and completely spared and shifted cranially. Here there is clear adhesion of the metastasis at the base of the sternocleidocleidomastoid muscle and level V between the sternocleidomastoid and trapezius muscles. Here, sharp dissection up to the tip of the mastoid and complete separation of the insertion from the mastoid. Further dissection deep into level Va until the prevertebral muscles (splenius and levator scapulae muscles) are identified. Here further dissection caudally and anteriorly until identification of the R. and N. accessorius at the posterior edge of the sternocleidomastoid muscle. Careful inspection of level II and affected structures. Decision to perform a radical neck resection, as the metastasis is clearly growing on the above-mentioned structures. Next, the sternocleidomastoid muscle is sharply separated at the transition from the cranial to the middle 1/3. Careful coagulation at the edge of the detachment. The accessorius nerve is ligated and sharply separated. The internal jugular vein is then ligated and sutured twice and then sharply separated. Dissection along the common carotid artery and external and internal carotid artery in a cranial direction. Exposure of the hypoglossal nerve, vagus nerve and symptomatic trunk in the carotid space. Branches of the cervical plexus in the area of level II are also sharply dissected. Now dissect further anteriorly and include the facial vein and the posterior edge of the masseter muscle at the posterior edge of the mandible. Dissection deep into the masseteric space, here the metastasis grows together practically up to the base of the skull. Further sharp separation of the metastasis from the external and internal carotid artery along the cervical vascular sheath. Now demonstration on <CLINICIAN_NAME> and takeover of the operation. The metastasis is now first dissected sharply at the base of the skull along the internal and external carotid artery. In the further course, clear adhesion of the metastasis to the external carotid artery and questionable infiltration of the hypoglossal nerve and internal carotid artery. Successive separation of the remainder of the metastasis at the base of the skull above the atlas and lateral to the styloid process. Due to severe bleeding in the area of the stylomastoid foramen, the main trunk of the facial nerve is coagulated but not severed. Here, stimulation of the main branch results in a complete nerve block approx. 0.5 cm from the stylomastoid foramen. The main branch of the facial nerve can be completely stimulated with 0.5 mA from this nerve block. Decision to ligate the external carotid artery and resection of the hypoglossal nerve and internal carotid artery to the base of the skull. Neck dissection together with the parotid leaf is sent in one piece for histological analysis, level Ia and level IV are marked separately with the suture for orientation. Next, dissection along the external carotid artery. This is ligated twice caudally after the exit of the superior thyroid vein and then punctured and sharply separated. The third branch of the lingual artery is also ligated twice and then sharply separated. The third branch of the external carotid artery, facial artery, is also ligated twice and sharply separated. The remainder of the external carotid artery is then traced together with the hypoglossal nerve and sharply separated from the carotid fascia and from the vagus nerve and internal carotid artery. This preparation is sent separately for histological analysis. A large defect remains at the base of the skull from the jugular fossa over the petrous bone to the carotid foramen. The wound is then thoroughly irrigated and careful hemostasis with ligation and bipolar electrocoagulation. The remainder of the sternocleidomatoid muscle is sutured to the platysma to reconstruct the neck contour. Two size 10 Redon drains are inserted caudally. The facial nerve trunk is carefully covered with Tabotamp. Careful wound closure. Redon drainage is inspected again, it works perfectly. The defect on the left edge of the tongue is now inspected. Relatively dry conditions here. Due to R0 frozen section diagnostics, a decision is made to close the wound primarily. Careful primary closure and plastic reconstruction of the defect at the edge of the tongue on the left is performed. If the swelling at the uvula and base of the tongue is relatively mild, the decision is made to transfer the patient to the IOI for overnight monitoring. The patient is then handed over to the anesthesiologist. End of the surgical procedure. Conclusion: Complication-free performance of a rapid incision-controlled resection of the tongue margin carcinoma on the left, extended radical neck dissection from level I to level V on the left and partial parotidectomy with intraoperative facial nerve monitoring and PEG placement. Panendoscopy revealed a left tongue ulcer, so that a diagnosis was confirmed via frozen section. Intraoperative a metastasis growing from the caudal parotid pole to the skull base and levels IIa, IIb and V. Difficult conditions in the area of the skull base due to adhesions to the external carotid artery and questionable adhesions to the internal carotid artery. Overall an unsafe resection in the area of the internal carotid artery and skull base. An R1 situation is possible here. The accessorius nerve, internal jugular vein, cranial edge of the sternocleidomastoid muscle, hypoglossal nerve, external carotid artery and cranial part of the cervical plexus and cranial part of the sympathetic plexus are sacrificed intraoperatively. Postoperative radiotherapy should always be carried out if infiltration of the internal carotid artery is questionable. Rapid and aggressive rehabilitation due to shoulder function as well as speech and swallowing due to hypoglossal sacrifice and sacrifice of the accessory nerve. Cortisone therapy tapered off for the next 7 days due to injury to the main facial nerve trunk. The facial nerve should be given at least 6-12 months to recover. Redon ex please after progression. Further procedure and presentation of the patient to the tumor board after receipt of the final histology. One night of monitoring for IOI due to slight swelling at the base of the tongue and uvula.