Initially after bronchoscopic intubation transnasally via the anesthesia colleagues, start with PEG insertion. For this purpose, insertion with the gastroscope under laryngoscopic control. Easy to see through to the stomach. There are clear signs of chronic gastritis with cobblestone-like changes to the mucosa and petechial bleeding, but no suspicious changes. With excellent diaphanoscopy, the stomach was punctured without any problems and the PEG tube was inserted using the usual thread pull-through method. On reflection, inconspicuous mucosal findings in the area of the oesophagus. After positioning and preparing the patient, a pharyngoscopy is performed. This reveals an exophytic tumor on the right side of the left tonsil region which extends over the anterior palatal arch into the uvula. Soft palate infiltration here at the free edge. Good distance to the hard palate. Complete infiltration of the posterior palatal arch. The posterior pharyngeal wall itself is again tumor-free. At the caudal tonsil pole there is an extension towards the pharyngeal side wall, here the tumor is clearly immobile, in the cranial tonsil area good mobility of the tumor. Insertion of the tonsil plug, good overview below. Transoral resection of the tumor using the monopolar and dissection technique. Select a safety margin of a good 1 ˝ cm, take the uvula with you, enter on the left side, subtotal resection of the soft palate to obtain the safety margin. Now good overview, here no dorsal growth towards the nasopharynx. Good delineation here. Complete resection of the anterior palatal arch. Here the tumor can be safely dissected away with a clear shifting layer to the musculature. Removal of the entire posterior palatal arch, resection up to approx. half of the posterior pharyngeal wall. Resection down to the prevertebral fascia. Now in the direction of the caudal tonsil pole, it can be seen that the tumor clearly extends like a cone towards the neck and the course of the carotid artery. This is confirmed by the CT findings. Therefore, the decision was made to obtain enoral mucosa-covering margin samples and to resect further transcervically. The marginal samples were found to be tumor-free in the frozen section diagnosis. Now turn to the neck dissection on the right side and complete the tumor resection. Skin incision at the anterior margin of the sternocleidomastoid muscle. Cut through the skin and subcutaneous tissue. Exposure and preservation of the external jugular vein, an anterior course is ligated and removed. Exposure of the sternocleidomastoid muscle. Exposure of the omohyoid muscle. Exposure of the submandibular gland and the digastric muscle. A clear lymph node conglomerate can now be seen in Level II to III in the area of the jugulo-facial angle, which is firmly attached and palpable in the direction of the tonsil lobe. In addition, multiple spherical, coarse and caked, highly suspicious nodes are palpable throughout level 5. Expose the accessory nerve and secure the nerve. Now open dissection of the internal jugular vein. Clear the anterior neck preparation while preserving the superior thyroid artery and securing the hypoglossal nerve. The lymph node conglomerate is directly exposed here. First remove the accessorius triangle and level 5, where the lymph node conglomerate is clearly embedded and infiltrated in the cervical plexus. This is now subtotally resected, the lymph node conglomerate extends nuchally directly under the skin. Sharp detachment at the skin with in sano resection. Macroscopically no lymph node openings. Resection up to level 5, ligation and removal of the transverse cervical artery and the very strong accompanying veins. Resection up to the mediastinum, but no further dissection here, no exposure of the subclavian vein, finally no evidence of lymph leakage. The cervical plexus here is subtotally resected, preserved accssorius nerve. Now ligate in the area of the jugulo-facial angle with partial but clear infiltration of the V. facilais and remove the vein. Expose the carotid artery with exit of the superior thyroid artery, the lingual artery extends into the lymph node conglomerate and is questionably infiltrated, this is ligated and removed. Dissection of the hypoglossal nerve, which is clearly adjacent but not infiltrated. Now expose the external carotid artery, after securing the bulb and the outlet of the internal carotid artery. It is now apparent that the cervical lymph node conglomerate is continuously moving in the direction of the tumor, therefore en bloc resection, resection was already performed previously. Now resection of the digastric muscle, resection and connection of the inner and outer resection surfaces in the area of the posterior pharyngeal wall, passing the external carotid artery, safe removal of the tumor here, now only the carotid artery and the prevertebral fascia remain dorsally. With careful protection of the hypoglossal nerve, resection of the tumor with at least 1 ˝ cm mucosal clearance. Resection extends to the level of the vallecula. This results in an en bloc resection of the tumor with the lymph node conglomerate extending cervically. To assess the tumor in frozen section diagnostics, however, the attached lymph node conglomerate is now removed and specially marked using a ligature. The specimen is thread-marked for frozen section diagnostics. Except for the deliberately placed margin, tumor-free margins are visible on all sides, so the situation is now R0. Now measure the enoral defect and lift a radialis graft from the left forearm parallel to the neck dissection performed here. After marking the 11 x 6 cm graft, the arm is unwrapped and the tourniquet is placed. Cut around the specimen, take along the cephalic vein and a skin monitor. Exposure of the cephalic vein. Performing the Hayden maneuver and exposing the ramus superficialis nervi radialis and exposing the peripheral vascular pedicle. Ligation of the vascular pedicle. Now careful subpastial preparation with careful protection of the radial nerve branch, free preparation of the graft up to the crook of the elbow. Here the very strong ulnar artery and the relatively slender anterior interosseous artery are secured. Preservation of both vessels. Now expose the wide venous bridge to the superficial venous system. Preservation of the bridge, elevation of a strong cubital venous branch. Reopening of the tourniquet. Regular flap vitality can be seen. Careful wound inspection and hemostasis. Later removal of the graft before insertion with removal of the artery and preservation of the anterior interosseous artery. After hemostasis, careful, two-layer wound closure and incorporation of the full-thickness skin graft lifted from the right groin. Finally, insertion of a vacuum sealing bandage and application of the Cramer splint. For full-thickness skin harvesting, cut around an 11 x 6 cm skin graft in the right groin. Strictly cutaneous elevation of the graft. Careful hemostasis, subcutaneous mobilization of the surrounding tissue and, after insertion of a 10-gauge Redon drainage, careful two-layer wound closure and application of a wound dressing. Now first perform the neck dissection on the left side. To do this, also make a skin incision on the front edge of the sternocleidomastoid muscle. Cut through the skin and subcutaneous tissue. Exposure of the external jugular vein and the auricularis magnus nerve. Preservation of the structures. However, the external jugular vein is relatively weak here. Exposure of the sternocleidomastoid muscle. Exposure of the omohyoid muscle. Exposure of the submandibular gland and the digastric muscle. Exposure of the anterior neck preparation with careful protection of the cervical artery, the superior thyroid artery, the facial vein and the hypoglossal nerve. Exposure of the accessorius nerve, free preparation of the internal jugular vein. There are no conspicuous changes at levels 2 to 4, but again at level 5 a partly conglomerate-like, coarse lymph node and macroscopically, palpatorily clearly suspicious, but here without infiltration of the surrounding tissue. Therefore, after evacuation of the accessorius triangle and careful preservation of the nerve, resection of the lymph nodes and preservation of the cervical plexus. Careful caudal inspection. Exposure and preservation of the transverse cervical artery, no evidence of lymphatic leakage caudally and, after careful inspection, wound irrigation with Ringer's solution and careful two-layer wound closure after insertion of a 10-gauge Redon drain. The tracheotomy is now performed due to the resection defect which extends to the hypopharyngeal side wall. For this purpose, a horizontal skin incision of approx. 1 cm below the cricoid cartilage is made. Cut through the skin and subcutaneous tissue. Exposure and transection of the intrahyoid musculature. Exposure of the cricoid cartilage. Exposure of the anterior surface of the trachea. Bipolar coagulation of the thyroid isthmus, which is very weak here. Insertion between the 2nd and 3rd tracheal ring. Creation of a broad-based pedicled Björ flap and successive incision of the tracheostoma with mucocutaneous anastomosis. Subsequent intubation with an 8 mm Woodbridge tube. At the end of the procedure, reintubation without difficulty onto an 8-gauge cannula, which is fixed with sutures and padded with foam. The graft is now inserted. To do this, pull the graft through from transcervical to transoral. First suture the posterior wall of the soft palate. Knock back the graft and reconstruct the soft palate and suture in the area of the tonsil lobe from the enoral side. Finally, transcervical suturing of the graft in the area of the pharyngeal side wall. Final inspection, good fit and correct measurements. Now positioning of the vascular pedicle. Insertion of the skin monitor. Now conditioning of the graft vessels. Conditioning of the superior thyroid artery, which is relatively similar in caliber to the graft artery. Perform the vascular anastomosis with 8.0 Ethilon, carefully adapting the vessel diameters. After reopening, good venous return via the graft. With regular graft perfusion to the venous anastomosis, initial conditioning of the external jugular vein, which remains the same caliber after removal due to the metastases of the facial vein. However, the vein is anastomosed over a long distance, even after removal of the thrombus and repeated irrigation, there is no adequate venous return, so this vein is ligated and removed. Now use of a superior thyroid vein trunk suture to the internal jugular vein, peripheral placement after ligation. Measurement of a size 3.5 coupler and problem-free performance of the copupler anastomosis. Immediate regular venous return and, after reopening of the artery, good circulation and regular flap perfusion as well as excellent flap perfusion in the area of the skin monitor and enorally. Careful positioning of the pedicle and partial fixation to the omohyoid muscle is now performed. Now stable conditions in the area of the anastomosis and especially in the area of the venous anastomosis close to the trunk, which is strong and therefore at risk of kinking. Final inspection. Due to the dissection in level 5 of the extended wound cavity, a 10-gauge Redon drain is placed here. There is livid skin discoloration in the area of the direct subcutaneous dissection performed, but the surrounding skin is intact with subcutaneous tissue also present, so no resection is performed here. Careful two-layer wound closure. Multiple vitality checks of the flap and skin monitoring and termination of the procedure at this point. Conclusion: Combined transoral, transcervical resection of a markedly aggressive lymphogenic metastatic cT2 cN2c oropharyngeal carcinoma on the right. Intraoperative R0 situation due to the intraoperatively extensive and aggressive metastasis, adjuvant RCT is certainly absolutely necessary here due to the atypical metastasis localization, however, a second malignancy should also be considered in the differential diagnosis. Postoperatively, please perform regular flap vitality checks. Post-operative X-ray preeclampsia on the 8th to 9th postoperative day, followed by a swallowing test if the conditions are intact and, if necessary, a diet with decannulation. In the immediate postoperative course, please check the nuchal skin area where there is a potential risk of necrosis. The patient received intraoperative antibiotics with Unacid 3 g and a single dose of SDH 250 mg. No abnormalities regarding the coagulation situation intraoperatively.