After induction of anesthesia and intubation by the anesthesiology colleagues, the patient is first positioned and then the small water tube is inserted under dental protection. After inspection of the inconspicuous oral vestibule. The oral cavity is inconspicuous. In the area of the oropharynx, the tonsils are scarred and cryptic on both sides, slight asymmetry in favor of the left side, but no exophytic tumor. The base of the tongue is seen on the left side with questionable slight tissue plus, otherwise macroscopically not suspicious. The rest of the oropharynx is unremarkable and clear, as are the endolarynx and the hypopharynx, which is slightly edematous and cannot be fully adjusted due to the physiognomy, but is clear as far as can be assessed. Inconspicuous postcricoid region. Corresponding to the diagnostic imaging, a diagnostic tonsillectomy is now performed on the left side and, in the case of slightly raised findings in the area of the base of the tongue, a representative biopsy of the base of the tongue is taken. Tonsillectomy performed using the classic dissection technique. Significant scarring of the tonsil capsule, but rather no tumor growth, therefore initially no resection towards the parapharyngeal space due to the extensive metastasis. Protection of the parauvular mucosal triangle and the posterior palatal arch and removal of the tonsil in toto. Careful hemostasis. Inspection of the tonsil after removal reveals an exophytic change after opening in the area of the cranial tonsil pole or here in the area of the crypts, which is highly suspicious, so the specimen is thread-marked and sent for frozen section diagnostics. This confirms the clinical suspicion of a tonsillar carcinoma, CIS forming margins in the area of the cranial pole, otherwise an R0 situation at all levels. Therefore, complete resection of the cranial tonsil ........., partly with soft palate-parauvular tissue and upper part of the posterior palatal arch. Complete imaging margin specimen. In the frozen section diagnostics, this is again completely tumor-free, therefore safe R0 resection here. The sample taken from the base of the tongue was tumor-free. In the meantime, the PEG was inserted. This was done with the gastroscope under laryngoscopic control. Easy to see through to the stomach. This was inconspicuous and clear. With good diaphanoscopy, problem-free puncture of the stomach and insertion of the PEG tube using the usual thread pull-through method. On reflection, the esophagus is clear and unremarkable. We now turn to the neck dissection. A coarse, moderately displaceable mass measuring clinically approx. 8 x 8 cm with clear infiltration of the sternocleidomastoid muscle is seen. The skin incision is now made from the mastoid to the anterior edge of the sternocleidomastoid muscle. Cut through the skin and subcutaneous tissue. Expose and cut through the platysma. This is clearly not infiltrated. Dissection of the platysma. Exposure of the sternocleidomastoid muscle in the caudal part. Exposure of the omohyoid muscle. Exposure of the submandibular gland and the digastric muscle. The cranial part of the sternocleidomastoid muscle is completely infiltrated up to just before the mastoid insertion. Ligation and removal of the external jugular vein and the auricular nerve. Separation of the sternocleidomastoid muscle at the level of the omohyoid muscle. Exposure and dissection of the internal jugular vein. Overall, significantly more difficult preparation conditions due to the patient's physiognomy. It can now be seen that the metastasis surrounds the cervical vascular sheath by approx. 180° and clearly extends to level V a. Here, subtotal infiltration of the cervical plexus, as well as infiltration of the phrenic nerve and the border cord. In addition, infiltration of the paravertebral musculature. En bloc resection here of the metastasis. Separation of the sternocleidomastoid muscle at the mastoid. Separation of the internal jugular vein. Anterior free dissection and preservation of the superior thyroid artery. The facial vein is removed during infiltration. Dissection of the caudal parotid pole. This works well. No infiltration here. There is now a circumscribed infiltration of the posterior digastric venter muscle. This is also generously resected. Infiltration of the barely visible hypoglossal nerve. Complete infiltration of the accessorius nerve. Now dissection directly onto the common carotid artery. Exposure and securing of the vagus nerve. Shortly after the exit of the superior thyroid artery, the external carotid artery is seen to be infiltrated. This is also removed. Removal of the infiltrated branch of the facial artery. Resection of the metastasis cranially up to the transverse process of the atlas and close to the spinal column, but here still covering the muscle layer. No tumor growth cranial to the digastric muscle, so that the metastasis can be removed in toto without opening the pharynx. Careful hemostasis. Evacuation of level V a and b remnants. Finally, no evidence of lymphatic leakage. Protection of the transverse cervical artery. Extensive wound irrigation with H2O2 and Ringer's solution and, if the wound is absolutely dry, insertion of two 10-gauge Redon drains if the wound area is extensive. Subsequent careful, two-layer wound closure. Final enoral inspection, in this case dry conditions. To further reduce the pharyngo-cervical fistula, the posterior and anterior palatal arch is adapted using 3-0 Vicryl mucosal sutures. Completion of the procedure with slim mucosa conditions. Conclusion: Intraoperatively histologically confirmed cT1 cN3 G2 R0 left tonsillar carcinoma. Please leave the Redon drains in place for at least 3 days due to the extensive wound cavity and plan adjuvant radiochemotherapy promptly.