After induction of anesthesia by the anesthesia colleagues, tracheoscopy by the surgeon. The trachea is visible up to the bifurcation. Subsequent intubation by the anesthesia colleagues. Repositioning for hypopharyngo-laryngoscopy. Entry with the Kleinsasser C-tube and inspection of the base of the tongue, epiglottic vallecula, right and left piriform sinus, postcricoidal region and esophageal entrance. No pathological changes here. Using the large double spoon, several samples are now taken from the base of the tongue on the right and left sides, which are sent for final histology. The endolarynx is then adjusted. No pathological changes here either. Repositioning for tonsillectomy on both sides. Insertion of the McIVOR oral spatula and palpation of the base of the tongue, floor of the mouth and the tonsils on both sides. No pathological resistance here. The tonsils are symmetrical on both sides and relatively atrophic. Start with tonsillectomy on the right side. Mucosal incision at the upper fold. Exposure of the tonsil capsule. Extension of the mucosal incision at the anterior posterior arch caudally and successive detachment of the tonsil from the capsule with the rasparatorium while sparing the anterior and posterior palatal arch. Separation of the tonsil at the caudal pole and bipolar coagulation of the caudal pole. There is no bleeding in the tonsil lobe on the right. Insertion of a hydrogen-soaked swab. Approach for tonsillectomy on the left side. Identical procedure here. No bleeding here either, after exposing the tonsil capsule and detaching the tonsil up to the caudal pole. Here, too, the palatal arch was spared anteriorly and posteriorly. Also bipolar coagulation at the caudal tonsil pole. Insertion of a hydrogen-soaked swab. Removal of the hydrogen-soaked swab. No evidence of further bleeding. Insertion of the velotraction and visualization of the nasopharynx. The posterior edge of the septum is clear, the tubal bulges are also unremarkable. No indication of a pathological change. Incision with Beckmann's ring knife and removal of minimal residual adenoids. Hemostasis using a hydrogen-soaked swab. No evidence of further bleeding after removal of the swab. Transfer for esophagoscopy and PEG placement. Entering with the esophagoscope under constant air insufflation into the stomach and distension of the stomach. There is a clear diaphanoscopy, despite obesity. Under the lower left paramedian rib, sterile draping. Injection of Ultracaine. Incision and puncture of the trocar without complications. Subsequent placement of the PEG using the thread pull-through method without problems. Repositioning for neck dissection on the left side. Injection of 6 ml ultracaine solution. Creation of an arched skin incision starting at the mastoid, pulling along the posterior sternal border in an anterior direction. This incision is chosen because the relatively large metastasis is located on the anterior edge of the sternocleidomastoid. Sterile covering. Cut through the subcutaneous tissue. Exposure of the platysma and creation of the platysmal flap. Locate the sternocleidomastoid and dissect the anterior edge of the muscle in depth. Successive detachment of the muscle. The auricularis magnus nerve is exposed in the anterior region. This is dissected and displaced caudally without severing it. The omohypoid muscle is then exposed and the retractor is inserted caudally. It can be seen that at the anterior edge of the sternocleidomastoid muscle from level II b to III, the metastasis is directly adjacent to the muscle without infiltrating it. Successive detachment of the metastasis in the cranial region from the muscle and search for the digastric muscle. Dissection of the digastric muscle and insertion of the cranial retractor. The accessorius nerve can then be exposed. This is spared until the end of the operation. Now dissect around the large cervical metastasis and detach the metastasis from level I after exposing the submandibular gland, which is pulled cranially with the Langebeck. Dissection around level II b up to level III. Now successive release of the metastasis, whereby a little thick secretion is emptied from the metastasis in the cranial region. Now visualization of the internal jugular vein and the facial vein. The internal jugular vein is displaced posteriorly/dorsally by the tumor, but can be spared. Dissection also reveals the cervical vein, which is traced in an anterior and caudal direction and is also spared until the end of the operation. Another small lymph node is found caudal to the mass, which is removed with the entire neck preparation. Subsequent dissection along the cervical vascular sheath and detachment of the fatty tissue from levels II and III up to level IV, with ligation in the caudal area to avoid a chyle fistula. No intraoperative evidence of chyle flow. Now turn to level II a. Here, the remaining fatty tissue cranial to the accessorius nerve is successively detached from the scalene muscles and then removed. Finally, the wound is irrigated with H2O2 and Ringer's and checked for hemostasis, which is present. Insertion of a Redon drain. Two-layer wound closure and completion of the procedure without complications. Conclusion: No evidence of primarius in the CUP panendoscopy. A TE/AT and trial biopsy from the base of the tongue on the right, left and median as well as a neck dissection on the left were performed.  