After preparation and intubation by the anesthesia colleagues, a pharyngo-laryngoscopy was performed to determine the current extent of the tumor. A coarse exulcerated tumor of the right tonsillar lobe was found, here coarsely seated and not displaceable. Infiltration of the soft palate also submucosal to parauvular on the right. Growth up to the dorsal maxilla. Growth circumscribed to the alveolar ridge. Growth to buccal over the glossotonsillar groove and the posterior floor of the mouth. Infiltration of the edge of the tongue and also the base of the tongue, here about Ľ infiltrated. Posterior palatal arch is reached. Also the caudal, former tonsil pole. No further tumor growth further caudally. Ultrasonography shows a cN2b neck status with infiltration of the internal jugular vein. The tumor is now resected transorally. Incision of the tumor with a safety margin of a good 1 cm and subtotal removal of the soft palate. Resection up to the left tonsil lobe. Subtotal removal of the soft palate. Resection up to the cheek. Exposure of the maxillary bone. Removal of the last gingival pocket and thus pushing the tumor away from the maxilla, which is growing close here, but certainly not breaking through the periosteum. The same procedure is now performed on the mandibular branch via the buccal side. View of the ascending mandibular branch. The tumor grows here, but does not reach the periosteum. From the inside, pushing off the periosteum in the posterior region. Close growth to the periosteum. Here the entire periosteum is pushed away from the posterior mandible, resulting in a good solution. A clear infiltration of the pharyngeal musculature can now be seen in depth. This is resected subtotally. Growth up to the pterygoid musculature. Circumscribed infiltration here. Overall, however, good mobilization of the tumour, so that the tumour can be mobilized cranially after detachment of the musculature with a clear safety margin. Resection of the posterior floor of the mouth and the edge of the tongue, maintaining a safety margin of 1 ˝ cm in the area of the tongue. Removal of the tumor in the area of the tongue down to the base of the tongue. It can now be seen that the tumor has broken through to the cervical region via the posterior floor of the mouth and laterally via the base of the tongue. Partial infiltration of the submandibular gland, which is already visualized enorally. Exposure of the lingual nerve, which is broad anteriorly but clearly infiltrated by the tumor dorsally. This is later removed. Due to the growth, the decision was made to proceed with a combined procedure and further transcervical resection. Therefore, repositioning for neck dissection of the right side. Curved skin incision on the anterior edge of the sternocleidomastoid muscle. Cut through skin and subcutaneous tissue. Exposure and dissection of the platysma. Exposure of the sternocleidomastoid muscle with careful preservation of the extremely strong external jugular vein. A clear infiltration of the muscle by the metastasis located in level II can already be seen in the upper area of the sternocleidomastoid muscle. Clear infiltration. Now caudal visualization of the entire sternocleidomastoid muscle. Exposure of the omohyoid muscle. Separation of the sternocleidomastoid muscle and cranial dissection. A markedly coarsely growing mass is seen in levels II and III, with a structure that most closely resembles a soft tissue metastasis. The internal jugular vein is now visualized. Cranial dissection. The vein is also clearly infiltrated in the middle area. The vein is therefore removed after securing the common carotid artery and the vagus nerve. Cranial dissection. The accessor nerve can be found below the trapezius muscle, but is clearly infiltrated medially and is also resected later. The metastasis grows close to the carotid bulb. The superior thyroid artery can be secured. The lingual artery must be removed later if the tumor grows, as must the facial artery. Careful dissection in the area of the bulb. Exposure of the hypoglossal nerve. Careful dissection of the nerve, the carotid bulb and the hypoglossal nerve can be preserved at the end. Securing the internal carotid artery. Certainly no tumor growth here, the rest of the external carotid artery is again free. A small tumor cone can now be dissected on the carotid artery in the direction of the primary tumor. Careful release of the cone. Removal of all surrounding tissue. Cranial removal of the internal jugular vein. The tumor cone can be followed towards the posterior floor of the mouth. Release of the submandibular gland, which is not infiltrated in the caudal part. Perform the pharyngotomy via the extirpation of the submandibular gland. Extend the pharyngotomy and complete the tumor resection, including the infiltrated floor of the mouth, and include the base of the tongue, resecting a good 1/3 of the base of the tongue. Overall, there is a clear breakthrough into the muscles of the floor of the mouth via the base of the tongue and the posterior floor of the mouth, resulting in a cT4a finding. The entire tumor specimen is thread-marked in toto with adjacent soft tissue metastasis for definitive histology. Enorally, all mucosal margins are provided with margin samples. This shows an R0 resection for the invasive carcinoma on all sides. Only the area of the floor of the mouth shows circumscribed CIS. Therefore, a generous resection and a new margin sample were performed here. Here, too, CIS was suspected, so that after a further resection a final specimen was taken, which was then assessed in the frozen section as completely free of tumor and dysplasia, so that overall an R0 resection with extensive growing cT4a oropharyngeal carcinoma with breakthrough and metastasis per continuitatem in the soft tissues of the neck can be assumed. The neck dissection is now completed. This involves clearing out level V while carefully sparing the cervical plexus branches. Also clear and complete level I b. Here too, several nodes measuring up to just under 2 cm. If the wound is dry, neck dissection of the left side and elevation of the radialis graft from the right forearm are now performed in parallel. Neck dissection of the left side. To do this, make a curved skin incision on the front edge of the sternocleidomastoid muscle. Cut through skin and subcutaneous tissue. Exposure and transection of the platysma. Exposure of the sternocleidomastoid muscle. Exposure and preservation of the external jugular vein. Exposure of the omohyoid muscle. Exposure of the submandibular gland and the digastric muscle. Dissection of the anterior neck preparation with careful protection of the superior thyroid artery, the cervical artery and the hypoglossal nerve. Dissection of the internal jugular vein. This shows a macroscopically suspicious mass in the jugulofacial angle, but without infiltration of the surrounding tissue. Exposure of the accessorius nerve. Excision of the accessorius triangle with careful protection of the nerve and excision of level V with careful protection of the cervical plexus branches. Final wound inspection. In dry conditions, wound irrigation with Ringer's solution and in dry wound conditions, insertion of a 10 Redon drain and careful, two-layer wound closure. Now to elevate the radialis graft. After marking the graft measuring up to 13 x 10 cm in total with a special configuration for the base of the tongue, floor of the mouth and soft palate. Creation of the tourniquet. Trimming of the graft. First radial preparation. This shows that the cephalic vein lies very far dorsally in the area of origin and is not in contact with the graft over a long distance, so that the cephalic vein does not need to be included. Exposure of the superficial radial nerve ramus, which can be completely spared. Exposure of the brachioradialis muscle. Exposure of the distal vascular pedicle. Dissection of the vascular pedicle. Ulnar dissection. Strictly subfascial release of the graft, leaving the peritendineum intact. Subsequent cranial dissection of the pedicle utilizing the entire pedicle position and left-sided anastomosis. A strong venous confluence can be seen here. Reopening of the tourniquet. A properly perfused graft is visible. Careful hemostasis and later removal of the graft after ligation of the vessel leading to ................ Subsequently, with dry wound conditions, careful, two-layer wound closure and harvesting of the full-thickness skin graft taken from the right groin. The vacuum pump is then applied and the Kramer splint is placed in the functional position. Removal of the full-thickness skin graft. To do this, cut around an area measuring 16 x 7.5 cm in total. Wider lifting is not possible due to increased skin tension. Incision of the graft. Strictly cutaneous lifting. Subcutaneous mobilization down to the fascia lata and the abdominal fascia. Subsequent insertion of a 10 Redon drain in dry wound conditions and multi-layer, subcutaneous wound closure and skin suturing. To incorporate the graft. For this purpose, combined transoral and transcervical suturing is performed using partially placed sutures. Difficult suturing conditions in the upper and lower jaw area. However, overall good fit, especially in the area of the caudal pharynx and the base of the tongue. Resection extending into the vallecula. Overall adequate fit here. In the meantime, the tracheotomy was performed. Horizontal skin incision at the level of the cricoid cartilage. Cut through the skin and subcutaneous tissue. Exposure and transection of the infrahyoid musculature. Exposure of the cricoid cartilage. Exposure of the anterior surface of the trachea. Dissection of the thyroid isthmus. Insertion between the 2nd and 3rd tracheal ring. Creation of a broad-based pedicled Björk flap and incision of the tracheostoma in the typical manner. Subsequently, transfer to a size 8 low-cuff cannula, which is suture-fixed. The cervical vessels are now prepared. The lingual artery is no longer sufficiently pervious or has an inadequate flow after the tube is removed, so the superior thyroid artery is now prepared. Excellent flow here. Preparation of the graft vessels. Then perform the arterial anastomosis with 8-0 Ethilon. This works relatively well even with unequal vessel calibers. Good adaptation. After reopening the blood flow, regular venous return flow and good pedicle pulsation immediately. Now prepare the external jugular vein. This is seen cranially with a questionably discrete thrombus. Open the vein. After removing a small amount of thrombotic material, excellent reflux, so that after measuring a size 3.0 coupler, anastomosis is performed with the coupler system. Subsequent regular circulation. Positive spreading phenomenon and regular pedicle pulsation as well as regular graft perfusion, so that after final wound inspection and wound irrigation with Ringer's solution, insertion of a 10 Redon drain and subsequent careful, two-layer wound closure. Final inspection of the graft and, if the graft is vital, termination of the procedure at this point. Conclusion: Intraoperatively R0-resected, extremely aggressive growing cT4a cN2c oropharyngeal carcinoma with perifocal CIS and metastasis per continuitatem in the soft tissues of the neck. Due to the resected surrounding musculature, a prolonged recovery of swallowing function can be expected. If the graft heals properly, the first clinical swallowing diagnostics can be carried out from the 9th postoperative day, followed by a diet if necessary. Due to tumor growth, adjuvant radiochemotherapy is urgently indicated.