After intubation by the anesthesia colleagues, a new pharyngoscopy is performed. Entry with the Kleinsasser tube under protection of the toothless chewing ridge. The oral cavity is unremarkable. On the right side, the exophytic change can be seen in the area of the right tonsil. This exceeds the caudal tonsillar pole and merges here with the caudal pharyngeal side wall, the overall extent is just cT2. The glossotonsillar groove is tumor-free. No transition to the base of the tongue. On mobilization, however, there is a spread to the posterior palatal arch at the mucosal level. No infiltration of the parauvular triangle. On the left side, the tonsil is somewhat bumpy and somewhat uneven on the surface. No extensive exophytic process at the site described above, only uneven mucosa. Therefore, in the case of palpable induration, first turn to tonsillectomy on the left side. This is done by removing the anterior palatal arch. Expose the tonsil capsule, this is certainly not exceeded. Detachment of the posterior palatal arch with sparing removal of some muscle. Separation at the lower pole with macroscopically inconspicuous conditions. The specimen is thread-marked for frozen section diagnostics. Turn to the right side. Cut around the carcinoma with a safety margin of 1 cm. Complete removal of the anterior palatal arch, the parauvular mucosa........ can be kept straight. Here too, the tonsil capsule is not exceeded, with some attached musculature on all sides. No exposed fatty tissue from the neck. Removal of some musculature from the posterior palatal arch and resection of the mucosal portion that exceeds the posterior palatal arch. Caudal separation in the area of the pharyngeal side wall with macroscopic in sano conditions. The frozen section diagnosis now shows a complete R0 situation for the right-sided carcinoma. On the left side, the margins are also free of carcinoma and dysplasia on all sides, but there is also no clear evidence of carcinoma intratonsillar. Therefore, if invasive carcinoma from the transition of the caudal part of the tonsil with transition to the base of the tongue is confirmed, complete resection of this area is carried out in the case of left-sided metastasis; this is done transorally under microscopic control as a laser resection with a 5 Watt CO2 laser. Adjustment of the area with the spreading tube. Resection of the left-sided tongue base edge of the pharyngo-epiglottic fold and the pharyngeal side wall. The resected area widely covers the previously described area. Completely covering and representative marginal samples are now taken, especially basally. Here, completely carcinoma- and dysplasia-free margin samples are found. In the central area of the post-resectate, Cis is found as a possible residual site of the biopsied tumor. Subsequent careful hemostasis. Due to the size of the resection, a protective tracheotomy is performed later. Otherwise, tissue transplantation can be dispensed with due to the localization of the defect. The left neck dissection is now performed. Selection of a submandibular approach. Cut through the skin and subcutaneous tissue. Exposure of the platysma. Dissection of the platysma. Exposure of the sternocleidomastoid muscle, omohyoid muscle. Glandula submandiblaris including the caudal capsule and the digastric muscle. Release of the anterior neck preparation with careful protection of the superior thyroid artery, the hypoglossal nerve and the cervical artery; the slender facial vein is removed later. Free preparation of the internal jugular vein. In the area of the jugulo-facial angle or level IIa, a livid, discolored and highly suspicious mass measuring approx. 3 cm can be seen, as well as smaller, also highly suspicious nodules in the surrounding area. Visualization and release of the accessorius nerve, which can be preserved. No reliable evidence of infiltration of the surrounding structures. Clearing of the accessorius triangle with careful protection of the nerve. Subsequent evacuation of level Va with careful protection of the cervical plexus branches. Wound irrigation with H202 and Ringer's solution and after careful wound inspection under dry conditions, insertion of a 10-gauge Redon drain and careful two-layer wound closure. Turn to the right side. Same procedure here in principle. Submandibular approach. After dissection of the platysma, exposure of the sternocleidomastoid muscle, omohyoid muscle and digastric muscle. Clearing of the anterior neck preparation and preservation of the superior thyroid artery and hypoglossal nerve. Level II shows several nodules up to 1.5 cm in size and macroscopically also appearing suspicious, also without infiltration of the surrounding structures. Exposure and free preparation of the accessorius nerve. Clearing of the accessorius triangle with careful nerve protection. Subsequent evacuation of level Va with careful protection of the cervical plexus branches. Followed by careful irrigation of the wound with H202 and Ringer's solution. Inspection of the wound area and, if the wound is dry, insertion of a 10-gauge Redon drain and careful two-layer wound closure. Then perform a plastic tracheostomy as a protective tracheostomy. Narrow, horizontal skin incision below the cricoid cartilage. Cut through skin and subcutaneous tissue. Exposure and splitting of the infrahyoid musculature. Exposure of the cricoid cartilage. Exposure of the anterior surface of the trachea. Insertion between the 2nd and 3rd tracheal rings. Performing a visor tracheotomy and fitting with adapting sutures. Subsequent problem-free transfer to a size 8 low cuff cannula which is suture-fixed. PEG insertion was performed at the beginning of the procedure. This was done with the gastroscope under laryngoscopic control. Easy to see through to the stomach. This was inconspicuous and clear. Now, with good pharyngoscopy, the stomach is punctured without any problems and the PEG tube is inserted using the usual thread pull-through method. The patient received intraoperative intravenous antibiotics with clindamycin, which should be continued for 24 hours postoperatively. Conclusion: Intraoperative R0 resected cT2 cN2b/c oropharyngeal carcinoma on the right. In addition, R0 resected cTis/cT1 oropharyngeal carcinoma on the left. Postoperatively, please abstain from food for approx. 4-5 days, after which the diet can be gradually built up. The tracheostomy is intended as a protective tracheostomy for 5-6 days. With regular enoral wound healing and adequate decongestion, direct decannulation can be performed. Presentation in our interdisciplinary tumor conference for adjuvant therapy that is certainly indicated.  