Initial inspection and palpation of the findings. There is an exulcerated mass in the area of the middle and cranial tonsil pole, clearly growing laterally submucosally. Here, however, it can be palpated and moved in depth. Parauvular triangle just free of tumor. No growth beyond the posterior palatal arch or beyond the caudal tonsil pole. Endoscopic PEG placement is performed first. This is done with the gastroscope under laryngoscopic control. Easy advancement into the stomach. Excellent diaphanoscopy. Problem-free puncture of the stomach and insertion of the PEG tube using the usual thread pull-through method. The stomach and oesophagus are otherwise unremarkable in the mirror findings. Now turn to transoral tumor resection. Insertion of the tonsil retractor and oral tumor resection in the sense of a radical tonsillectomy. Complete removal of the anterior palatal arch. Resection up to the parauvular level. There is a good displacement layer above the tumor in depth. Here complete in sano removal. Release of the tonsil at the transition to the base of the tongue, basally towards the posterior palatal arch, removal of muscles. No further tumor growth here. Deposition at the posterior palatal arch to the lower tonsil pole, macroscopically in sano. The specimen now only shows a small safety margin parauvularly due to shrinkage, otherwise a safety margin of at least 1.5 cm on all sides at the mucosal level. Basally, the tumor is intact, but due to the thin tissue conditions above the capsule, there is a narrow safety margin. A narrow resection is performed in the area of the soft palate and parauvularly to ensure R0 resection. The specimen and the additional marginal sample are thread-marked for frozen section diagnostics. All mucosal margins were found to be completely free of tumor and dysplasia. Only in the basal area is there a narrow R0 situation with a distance of just under 0.1 cm, but with tumor-free margins. The case and findings are now discussed with <CLINICIAN_NAME> due to the narrow basal resection margin. In the case of microscopic but narrow R0 resection, a corresponding post-resection or covering margin specimens are now created. For this purpose, superficial muscle resection. Covering of the area close to the capsule, which corresponds to the lateral tonsil bed. Finally, ablation of the musculature. Only a small amount of circumscribed prolapsing fatty tissue. This is coagulated. The surrounding and tumor capsule-covering musculature is diagnosed as completely tumor-free in the frozen section diagnosis. Therefore, an R0 resection can be assumed here. Careful wound inspection. Wound surface is clearly visible and can be explored. Two adapting sutures are now placed in the area of the parauvular mucosa. Here, too, the conditions towards the back of the soft palate are intact, so that good swallowing function appears to be guaranteed. The neck dissection of the right side is now performed during the frozen section pauses. For this, a submandibular skin incision is made. Cut through the skin and subcutaneous tissue. Exposure and dissection of the platysma. Creation of a platysma flap. Exposure of the sternocleidomastoid muscle and preservation of the external jugular vein. Exposure of the omohyoid muscle, the digastric muscle and the submandibular gland. Clearing out the anterior neck preparation while carefully protecting the cervical artery, the superior thyroid artery, the facial vein and the hypoglossal nerve. Exposure of the accessorius nerve. Clearing of level V a with careful protection of the cervical plexus branches after exposure and dissection of the cervical vascular sheath. Overall, no macroscopically highly suspicious masses. Careful wound inspection and, if the wound is dry, insertion of a 10-gauge Redon drain and careful, two-layer wound closure. Turn to the opposite side. Same procedure here in principle. Sonographically there is a cN2b neck status. Corresponding incision. Cut through skin and subcutaneous tissue. Dissection of the platysma. Exposure of the sternocleidomastoid muscle, the digastric muscle and the omohyoid muscle. Release of the submandibular gland. Palpation of rough, suspicious nodes in levels II a and II b with transition to level V a. Visualization of the accessorius nerve. This is free. Clearing of the anterior neck preparation with careful preservation of the superior thyroid artery, the facial vein, the cervical vein and the hypoglossal nerve. Free preparation of the internal jugular vein. A large metastasis measuring a good 3 cm can be seen in the jugulo-facial angle. Clearing of the accessorius triangle. Highly suspicious change here as well. Sparing involvement of the surrounding musculature. At the transition to level V a, it can now be seen that a highly suspicious nodule is infiltrating the cervical plexus in a circumscribed manner, so this must be resected in a circumscribed manner. Complete release up to the transition from level V b, also complete release below the cervical plexus. Overall in level II b and V a several small but highly visible lesions due to the macroscopic changes. Careful palpation of the supraclavicular and infraclavicular region as well as paravertebrally. No further nodules here. Therefore, after careful wound inspection, irrigation with H2 and Ringer's solution. Then insertion of a 10 Redon drain and careful, two-layer wound closure. Final enoral inspection again. Multiple checks for blood dryness. Circumscribed final hemostasis. However, if the wound is dry overall and the wound cavity is clearly visible, a tracheostomy is not performed due to the high degree of visual impairment and lack of swelling. The procedure was subsequently completed without any indication of complications. The patient received intraoperative antibiotics with Unacid 3 g. Please continue this for 24 hours postoperatively. The patient should abstain from food for at least 2 to 4 days, then carefully and gradually build up her diet. Due to the cervical metastasis, adjuvant therapy appears to be urgently required.