Initial consultation with the anesthesiologist. Pharyngoscopy is performed first: The tonsil tumor is seen after insertion of the McIvor blade. This is exophytically limited to the tonsil lobe, but palpation shows deep growth in a cranial and lateral direction and extends to the uvula. Posterior palatal arch also involved. Therefore confirmation of the operation with flap coverage. Placement of the PEG tube in the typical manner. Transoral tumor resection: The tumor is incised on all sides with a safety margin of 1-1.5 cm. The anterior and posterior palatal arches are removed. The soft tissue towards the hard palate is also resected with an appropriate safety margin. The resection also extends deep into the pterygoid muscles. Resection extends to the base of the tongue. Medially up to the posterior pharyngeal wall. The tumor specimen is removed in its entirety. Suture marks are placed. Marginal sample from the uvula and marginal sample from cranial-basal from the soft tissue above the tonsil towards the hard palate. The tumor is resected macroscopically in healthy tissue. However, the frozen section shows tumor infiltrates towards the posterior pharyngeal wall and in almost all areas basally. The marginal specimen of the uvula was healthy. Cranial-basal margin specimen with tumor. The patient is therefore repositioned. Covering of all relevant surgical areas after skin disinfection. Beginning with radical neck dissection on the right: skin incision in typical manner. Exposure of the anterior border of the sternocleidomastoid muscle. Exposure of the omohyoid muscle and digastric muscle. A large metastatic conglomerate is visible, which has infiltrated the sternocleidomastoid muscle, runs broadly in the direction of the lower parotid pole and towards the base of the skull, and has infiltrated the internal jugular vein. Depiction of the cervical vascular sheath. The external carotid artery as well as the hypoglossal nerve can only be separated from the metastatic conglomerate and preserved with difficulty. Exposure, displacement, neurolysis and re-embedding of the hypoglossal nerve. The internal carotid artery can be easily dissected during the procedure, as can the vagus nerve. This is relocated in the sense of a neurolysis and re-embedded. The internal jugular vein is infiltrated in the upper area. It is placed caudally and ligated twice. Cranially, the lower parotid pole must also be resected as the metastasis grows to this point. All the muscles of the styloid fan are removed. The styloid process must also be resected. Larger parts of the cervical plexus in the cranial part must be resected together with the deep neck muscles, as must of course the sternocleidomastoid muscle. The accessorius nerve is included in the preparation. The V. facialis and V. thyroidea can be preserved. The submandibular gland is also removed. An infiltration of the parapharyngeal space and growth along the internal carotid artery, hypoglossal nerve and vagus nerve can be seen towards the base of the skull. Soft tissue is removed from here, as well as from the area around the styloid process, which was also resected. Tissue is also removed from the right lower pole of the carotid artery. In the frozen section, infiltrations in the skull base margin sample, i.e. around the internal carotid artery and the large cranial nerves. The internal jugular vein was placed very close to the base of the skull and ligated twice. Infiltration by tumor cells, at least microscopically, is also possible here, but was not specifically confirmed by a sample. The tumor is now resected: the facial, superior thyroid and lingual arteries can be preserved. The hypoglossal nerve is also preserved after visualization. Defect in the area of the pharyngeal wall is visualized. The entire pharyngeal wall is resected, including larger parts of the posterior pharyngeal wall. Extensive resection in the area of the pterygoid muscles, which is also resected up to the level of the tube. A marginal sample is taken from the posterior pharyngeal wall from the level of the tube to the hypopharyngeal entrance and sent in labeled with a suture. A marginal sample is also taken caudal-basally from the area of the pharyngeal musculature at the hypopharyngeal entrance. Marginal sample from the cranial-basal area from the area of the remaining pterygoid muscles. A marginal sample was also taken from the transition from the posterior pharyngeal wall to the posterior palatal arch or nasopharyngeal mucosa area. In addition, a marginal sample was taken from the medial pterygoid muscle, which remained on the mandible and was also inconspicuous macroscopically. Infiltrates in the cranial-basal area in the frozen section. Therefore, another extensive soft tissue resection and marginal sample from the pterygoid muscle area next to the tube as well as a mucosal marginal sample with an extensive soft tissue mantle from the palatal mucosa in the hard palate. No more infiltrates here. Overall, an R1 situation is confirmed in the area of the base of the skull, along the cranial nerves and the internal carotid artery. As a final marginal sample, soft tissue was again removed from the entire area, including the spinal column and transition to the mastoid, and sent in for final diagnosis in order to obtain an overview of the extent of the R1 situation. R1 situation certainly also despite R0 situation after marginal samples in the area of the paratubular soft tissue in the pterygoid muscles and soft tissue remaining there. Overall now large defect from the nasopharynx to the hypopharyngeal entrance. Defect coverage using a radial flap is indicated. The defect is measured, resulting in a flap size of approx. 15x10 cm. Irrigation of the wound area with hydrogen and Ringer's solution and extensive hemostasis. Neck dissection on the left side: Here too, as on the opposite side, evacuation level II to V. The internal and external carotid arteries, internal jugular vein, facial vein, vagus nerve, accessorius nerve, hypoglossal nerve and branches of the cervical plexus are all exposed and preserved. The vagus nerve, hypoglossal nerve and vagus nerve are relocated and re-embedded by means of neurolysis. Level II lymph nodes in the cranial region have to be dissected from the jugular vein, but are not infiltrative there. Nevertheless, lymph node metastases are also clinically present here. Tracheostoma creation: Small Kocher collar incision. Exposure through subcutaneous tissue to the infrahyoid musculature. Splitting of these. Exposure of the thyroid isthmus. Undercutting of this, clamping of the same, severing and treatment by means of puncture ligatures. Exposure of the trachea. In the 2nd to 3rd intercartilaginous space, opening of the trachea and creation of a wide pedicled modified Björ flap. This is epithelized in the typical manner. Re-intubation and insertion of an 8 mm Woodbridge tube. Elevation of the forearm flap from the left forearm: Marking of the flap in the required three-dimensional dimension and size. Incision of the flap from ulnar subfascial. Incision in the crook of the elbow. Visualization of the superficial venous system with connection to the deep venous system. Subsequent exposure of the vascular pedicle below the brachioradialis muscle. Then elevation of the flap subfascially from the radial side. Exposure and preservation of the lateral antebrachial cutaneous nerve as far as possible given the size of the flap. Caudal exposure of the V. and A. radialis. After clamping for 10 minutes with good saturation, cut through. Treatment of the stumps using 4.0 Prolene single button sutures. Lift the flap successively along the stalk. Smaller vessels are clipped or bipolar coagulated. Exposure of the interosseous artery in the antecubital fossa. After clamping it for a few minutes, if it is well saturated, it is cut and clipped. Exposure of the entry of the radial artery into the brachial artery. Visualization of the confluence. This is split and not very suitable for anastomosis. Two good venous anastomosis options remain in the area of the cephalic vein. Removal of the flap. Veins are ligated. The brachial artery is supplied with 6.0 Vascufil. Flap is flushed with heparin. Split skin with a thickness of 0.8 mm is removed from the thigh area. Hydrocolloid dressing here. The forearm is primarily closed cranially after extensive hemostasis. Split skin is successively incorporated into the forearm defect. A Vacuseal dressing is applied over this in the typical manner. Suction 75 mmHg. Attachment of the arm. The radial artery flap is inserted into the defect. Successive suturing from transoral and transcervical, partly with the sutures in place. The flap can be sutured in place without tension. Replacement of the pharyngeal side wall and posterior pharyngeal wall and palatal arch. Sutured cranially to the tubal cartilage. The stalk is passed below the hypoglossal nerve into the soft tissues of the neck. The regions at the base of the skull showing the R1 situation were marked with clips beforehand. The vessels were then conditioned. The still outgoing V. facialis and V. thyroidea media are selected as connecting vessels. The facial artery is selected and anastomized with the radial artery after conditioning with 9.0 Ethilon single-button sutures. After opening the clamps, good arterial flow and good venous return. The larger cephalic vein is anastomosed to the facial vein with 4.0 couplers after conditioning. Good venous return after opening the clamps. Positive smear phenomenon. The smaller vein is anastomosed with the V. thyroidea media with a 2.5 mm coupler. Good venous return here too. Positive smear phenomenon. Overall good perfusion of the flap. Careful hemostasis and irrigation of the neck. Wound closure in layers on the right with insertion of two flaps. Application of a pressure bandage. Skin closure on the left with insertion of a Redon drain after extensive hemostasis and irrigation. Application of a pressure bandage. The epithelialized tracheostoma is supplied with an 8 mm tracheostomy tube. This is sutured in place. Wound dressing. Completion of the procedure without complications. Final consultation with the anesthesiologist. Conclusion: Overall cT4 tonsillar carcinoma with almost per continuitatem growth or contact with a very large soft tissue metastasis, which in turn showed infiltrations into the skull base or caudal parotid pole. Almost N3 metastasis on the right, total lymph node metastases on both sides. Overall extensive tumor volume, which justified resection to this extent in view of the HPV-positive status. Postoperative RCT indicated as soon as possible. Patient admitted to the intensive care unit for postoperative monitoring. Antibiotic treatment, which was started intraoperatively with Unacid 3 g, should be continued for one week. Feeding via the inserted PEG tube, after loosening the next day. Flap control enorally or by Doppler for five days. Heparin perfusor, which was started intraoperatively at 500 units/hour, should be continued for five days. X-ray pre-swallow on the 10th day, then diet build-up if necessary.