After preparation and intubation by the anesthesia colleagues, positioning of the patient. First insertion of the tonsil plug. After inspection of the inconspicuous oral cavity including the inconspicuous primary tumor area, inspection and palpation of the right tonsil lobe. Intact mucosa, no palpable submucosal mass. No correlation to the CT findings. Now consult <CLINICIAN_NAME>. Confirmation of the inconspicuous findings in the area of the tonsil lobe or oropharyngeal side wall here, and adjustment of the histologically confirmed findings, which had presented as a small punctate double ulcerative lesion. This can be visualized again under the surgical microscope. Two adjacent, very superficial, small ulcerative lesions are seen in the area of the pharyngoepiglottic fold and pharyngeal side wall with suspected small tumor cones in the direction of the piriform sinus entrance. With good adjustment and inconspicuous endoscopic findings in the area of the tonsil lobe, confirmation of laser resectability. After adjusting the tumor region with the B-tube, resection with the 2.0 watt CO2 laser, submucosal dissection, here tissue on all sides in healthy tissue. Incision of the lesion with a safety margin of approx. 5 mm, but partial resection of the pharyngeal side wall, the entire pharyngoepiglottic fold and the piriform sinus entrance. Basally intact conditions on all sides. Macroscopically hardly any penetration depth. Marginal samples are now taken completely covering the margins. In frozen section diagnostics, the margins of at least CIS are now tumor-free without higher grade dysplasia. Mild to moderate dysplasia in the cranial and dorsal area. After case discussion with <CLINICIAN_NAME>, no further measures. Minutious hemostasis and caudal insertion of a Tachosil fleece to prevent bleeding and a pocket. Subsequent PEG insertion: For this purpose, insertion with the gastroscope under laryngoscopic control. Easy pre-scanning into the stomach. With 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 were unremarkable during the endoscopy. Re-inspection of the resection area. In dry conditions, repositioning for neck dissection, initially on the right side: CT scan showed parapharyngeal tissue plus on the right side, as well as a mass adjacent to the deep parotid pole. In addition, there was also a mass in level VI retroclavicular. Injection of xylocaine with added adrenaline. Opening of the old scar on the anterior edge of the sternocleidomastoid muscle. Cutting through skin and subcutaneous tissue. Exposure and release of the already clearly scarred sternocleidomastoid muscle. Exposure and dissection of the internal jugular vein. This reveals level III or level IV, small nodules up to max. 5 mm. Exposure of the omohyoid muscle. Dissection, visualization of level V. Here, with intact cervical plexus, only scar plate. No further space-occupying lesions. Behind the sternocleidomastoid muscle, in front of the pretracheal musculature or retroclavicularly, a lump measuring approx. 2 x 1 cm with surrounding soft tissue can now be removed without difficulty in correspondence with the CT. The nodule is located on the subclavian vein, which is selectively exposed and safely protected. Nodus macroscopically suspicious. Careful palpation of the supraclavicular region or retroclavicular region, no further masses here. Now dissection and removal of little tissue from the anterior neck area. No suspicious nodules here. Pronounced scarring in the submandibular region. Careful exploration. No further nodules here either. Removal of little lymphatic tissue. Now cranial preparation. Exposure of the caudal parotid pole. A macroscopically clearly suspicious change measuring approx. 2 x 1 cm can be seen on the inner side with a small further attached mass, which is not necessarily suspicious. Mass between the atlas, transverse process and mandible. Removal of the mass with a rim of parotid tissue. A mass also medial to the parotid gland, but this is not necessarily suspicious. Dissection of the parapharyngeal tissue with restrained dissection towards the primary tumor area. Palpation and exploration up to the tonsil lobe. However, no larger masses could be visualized here. Previous exposure of the carotid artery, hypoglossal nerve and accessorius nerve. Protection of the structures. Final palpation of all regions and meticulous hemostasis if there are no visible masses. Wound irrigation with H2O2 and Ringer's solution. Subsequent insertion of a 10-gauge Redon drain and careful two-layer wound closure. Repositioning for neck dissection on the opposite side: the old scar is also used here. Skin incision on the front edge of the sternocleidomastoid muscle. Cut through skin and subcutaneous tissue. Cutting through remnants of the platysma. Exposure of the sternocleidomastoid muscle. Dissection of the scarred muscle. The internal jugular vein was resected during the previous operation. Therefore direct exposure of the common carotid artery. The vagus nerve and the border cord are visualized and are scarred and can be spared over their entire length. Level V is scarred and free with intact cervical plexus and accessorius nerve. Now first caudal dissection. Corresponding to the CT, a macroscopically highly suspicious mass measuring just under 3 x 1 cm, also located on the subclavian vein, can be seen in a similar position as on the opposite side behind the sternocleidomastoid retroclavicular muscle. This is also selectively dissected and spared. Careful palpation of the retroclavicular region. No further space-occupying lesions here. Now, after exposing remnants of the digastric muscle and the submandibular region, exploration. Here too, pronounced scarring, but no further masses. Careful dissection of the caudal parotid gland. Medial exploration. Removal of inconspicuous parapharyngeal tissue. Now medial dissection of the common carotid artery and the bulb in the case of a clearly suspicious parapharyngeal mass on CT. Dissection reveals a longitudinal oval mass measuring approx. 3 x 1 cm between the lateral pharyngeal wall and the carotid artery. This was macroscopically highly suspicious. Caudally a further approx. 1.5 cm also suspicious lump. Palpation of the retro- and parapharyngeal region up to the base of the skull. No further space-occupying lesions here, so that after final palpation, if there are no further nodules and no visible space-occupying lesions, hemostasis and irrigation with H2O2 and bovine solution are also performed. Then, if the wound is dry, a 10-gauge Redon drain is inserted and the wound is carefully closed in two layers. Finally, after a final case discussion with <CLINICIAN_NAME>, a plastic tracheostomy is performed and, in the case of a deep primary tumor, a protective tracheostomy. To do this, make a tight incision to avoid fistulation of the tracheostoma with the cervical wound. Cut through skin and subcutaneous tissue. Incision below the cricoid cartilage. Separation of skin and subcutaneous tissue. Longitudinal division of the linea alba. Exposure of the cricoid cartilage. Exposure of the anterior surface of the trachea. Dissection of the slender thyroid isthmus. Insertion between the 1st and 2nd tracheal ring. Creation of a broad-based pedicled Björk flap and insertion of the tracheostoma in the usual manner. Subsequent problem-free transfer to a size 8 low-cuff cannula, which was successful. The procedure was then completed without complications. The patient received intraoperative single-shot antibiotics with Unacid 3 g. Conclusion: Intraoperative R0 resected cT1 to cT2 oropharyngeal carcinoma on the right with rcN2c neck status overall conspicuous and highly irregular cervical metastasis on both sides after previous therapy. Due to the clear and irregular metastasis with limited surgical options, adjuvant RCT appears to be indicated. Due to the very discrete primary tumour, field cancerization is also possible. Postoperatively, please leave the protective tracheostomy in place for at least 7 days. Decannulation is then possible if enoral healing is regular and swallowing function is good.