After intubation by the anesthesia colleagues, the patient is positioned. First of all, PEG insertion: for this purpose, insertion with a flexible gastroscope under laryngoscopic control. Easy to see through to the stomach. This appears regular and free. With a regular diaphanoscopy, the stomach is punctured without any problems and the PEG tube is inserted using the usual suture pull-through method. This was without any problems. No abnormalities on inspection of the oesophagus, apart from a few tablet residues. First, a pharyngo/laryngoscopy was performed to determine the extent of the tumor: an exophytic and ulcerated tumor was found in the area of the left tonsil lobe, which was largely limited to the tonsil region. In the area of the right edge of the tongue, superficial fleshy, reddish tissue, questionable as a tumor extension, which shows no deep infiltration on palpation. Relatively good mobility on palpation of the tumor, no deep infiltration. Free posterior pharyngeal wall, no growth towards the nasopharynx. Further tongue base, vallecula and epiglottis are free. The caudal tonsil is relatively fleshy. Here rather no tumor growth. Therefore, we now turn to primary enoral resection. Expose the tumor with the tonsil retractor and the Jennings retractor while looping the tongue. Inclusion of the entire anterior palatal arch to gain an overview. Resection to just parauvular. Therefore good mobilization of the tumour. Resection of the tumor in toto with removal of muscles in the area of the posterior palatal arch. Here the tumor is smoothly bordered and encapsulated, without tissue adherence. Relatively easy detachment without capsular injury. Caudal resection is also problem-free. The fleshy change in the area of the right or posterior right edge of the tongue is now removed with a safety margin of a good 1 cm. Free conditions in the depth here. Removal of approx. 1/2 cm of muscle cuff. Circumscribed resection of the glossotonsillar groove. However, this otherwise remains largely intact. There is also no resection towards the floor of the mouth. Involvement of the entire tonsil including the caudal change. Therefore resection up to the level of the epiglottis. Minutious hemostasis using bipolar coagulation. After extirpation of the tumor, re-inspection. In the area of the posterior pharyngeal wall, a macroscopically narrow resection distance can be seen medially. The capsule of the tumor can be seen circumscribed caudally. However, there is no breakthrough or open tissue. Therefore, a complete resection was first made in the area of the posterior pharyngeal wall and parauvularly up to the caudal margin. Now insert the entire specimen, which is marked on all sides, and the resected specimen for frozen section diagnostics. With a short resection distance in the area of the posterior pharyngeal wall, the post-resection is now exposed here. Basally in the cranial part, the resection distance is very short here with the capsule partially exposed, as described. The resection margin in the area of the anterior palatal arch is also narrow, otherwise the resection margins are macroscopically and microscopically tumor-free on all sides, especially in the area of the tongue. Therefore, at a later stage, a resection and a final margin specimen are formed in the area of the entire anterior palatal arch and in the area of the wound bed in the area of the posterior palatal arch, covering it completely. The final marginal sample is diagnosed as tumor-free at both sites in the frozen section diagnostics. Therefore, no further measures are required. Minutious hemostasis and check for blood dryness. On palpation, even before the necks are performed, a clear soft tissue mantle is still visible in addition to the clearly palpable metastasis in level II on the right. Therefore, we now turn to the neck dissections, starting with the neck dissection on the left: After repositioning and instillation of xylocaine with the addition of adrenaline, start on the left side: curved skin incision submandibularly and on the anterior edge of the sternocleidomastoid. Cut through skin and subcutaneous tissue. Separation of the platysma. Creation of a platysma flap. Exposure of the sternocleidomastoid muscle, the omohyoid muscle. Exposure of the submandibular gland and the digastric muscle. Release of the anterior neck preparation with careful protection of the superior thyroid artery, the facial vein and the cervical vein. Free preparation of the internal jugular vein after prior exposure and protection of the accessorius nerve. Clearing of the accessorius triangle with careful protection of the nerve. Subsequent evacuation of level V with careful protection of the plexus branches. No evidence of lymphatic leakage caudally. Subsequent careful wound inspection and wound irrigation with Ringer's solution and, if wound conditions are dry and level IIa to V is completely evacuated, insertion of a 10 Redon drain in the case of clinical cN0 aspect and later careful two-layer wound closure after checking again for blood dryness. Turning now to the opposite side: Here also skin incision, submandibularly curved at the anterior edge of the sternocleidomastoid muscle. Cut through the skin and subcutaneous tissue. Separation of the platysma. Creation of a platysma flap. Palpation of the metastasis, which is mainly located in level IIa, appears to measure approx. 4 x 5 cm and is relatively easy to move with the surrounding area. Palpatorily no infiltration of the sternocleidomastoid muscle or adherence to other structures. Therefore, visualization of the sternocleidomastoid muscle at level II of the metastasis on the muscle without signs of muscle infiltration for ............. a safety margin. Inclusion of a circumscribed muscle cuff. Expose the omohyoid muscle at this point. Exposure of the submandibular gland. Exposure of the digastric muscle. Removal of the anterior neck preparation with exposure and preservation of the facial vein, the hypoglossal nerve and the superior thyroid artery. Ansa cervicalis was removed here. Now free preparation of the internal jugular vein. The large mass is seen in level IIa, lying directly on the vein in the area of the jugulofacial angle, but here there is no evidence of infiltration with strict vascular dissection. In addition, level III, located directly on the internal jugular vein, shows a nodular lymph node change measuring approx. 2 x 2 1/2 cm. Confirmation of the CT findings. Visualization of the accessorius nerve. The metastasis lies on the nerve, but clearly does not infiltrate it. The metastasis can be easily detached from the nerve. After complete visualization of the digastric muscle, detachment from the metastasis is also possible. Good caudal detachment from the caudal parotid pole. Here only adjacent metastasis, no evidence of infiltration. Overall metastasis limited to the lymph node, measuring approx. 4 x 5 cm, which is removed in toto. Finally, the accessorius triangle was removed, carefully sparing the nerves, and Levl V was removed, carefully sparing the plexus, with no evidence of lymphatic leakage. Now, after complete removal of the neck resectate, inspection of the wound cavities, especially palpation towards level IIa, towards the tonsil lobe. Here, palpation also reveals a clear soft tissue mantle and a well-protected carotid artery. Findings demo and case discussion with <CLINICIAN_NAME>. Due to the non-penetrating defect of the stable soft tissue mantle, confirmation of the extent and also no indication for radial flap coverage. Therefore, careful inspection of the wound surfaces. Irrigation with H2O2 and Ringer's solution. If the wound is dry, insertion of a 10 Redon drain and careful two-layer wound closure. The previously dictated resections are now carried out. Final wound inspection. After meticulous hemostasis, the wound is dry. A relatively large wound area is now visible. After resection of the anterior palatal arch, resection towards the soft palate, resection up to the posterior pharyngeal wall and resection in the area of the pharynx caudal to the level of the epiglottis as well as circumscribed resection of the edge of the tongue. Due to the large wound area and extent, the decision was made to perform a protective tracheostomy. Prior to this, the wound surfaces in the area of the tongue edge are adapted with 3.0 Vicryl. Also adaptation of muscle cords in the area of the posterior pharyngeal wall and parauvular tissue. Finally, inspection under dry conditions. Finally, perform the tracheotomy: modified Kocher collar incision, approx. 1 cm below the relatively deep cricoid cartilage. Very short distance between jugulum and cricoid cartilage. Cut through skin and subcutaneous tissue. A very strong, pronounced vein is seen subcutaneously, almost the caliber of an internal jugular vein. This is exposed, ligated and ligated. Further exposure of the infrahyoid musculature. Entering the linea alba. Exposure of the cricoid cartilage, exposure of the anterior surface of the trachea. The glandular isthmus is relatively weakly developed and is coagulated. Exposure of the anterior surface of the trachea. Insertion between the 2nd and 3rd tracheal ring. Creation of a Björk flap and insertion of the tracheostoma in the usual manner. Finally, problem-free transfer to an 8 mm tracheoflex cannula and completion of the procedure at this point. Conclusion: Intraoperative R0-resected cT2 cN2b oropharyngeal carcinoma on the right with protective tracheostomy and extensive resection area, but with good conditions for primary wound healing. After a swallowing test, a liquid diet can be started from the 3rd postoperative day. If swallowing function and wound development are normal, decannulation may be possible from the 5th to 7th postoperative day. After receiving the definitive histology, presentation at our interdisciplinary tumor conference. Due to the aggressive metastasis, adjuvant therapy is certainly required here.