Bulbar syndrome is a syndrome of foreign body sensation in the pharynx, sore throat or reflex otalgia, head and neck pain and increased salivary glands caused by stimulation of the adjacent vascular nerves due to excessive stem length or its abnormal orientation or morphology. Tonsillectomy is a common causative factor. Anatomy of Stem Overgrowth The stem is part of the hyoid chain, which is derived from the second branchial arch of Reichart’s cartilage. It has four separate embryonic parts: (1) the bulging tongue; (2) the stem tongue; (3) the angular tongue; and (4) the lower part of the hyoid bone. The apical part of the stem usually lies between the external carotid artery and the internal carotid artery, just above the bifurcation and more to the side of the external carotid artery. artery and is closely related to the external carotid artery. The internal carotid artery, internal jugular vein and accompanying, hypoglossal, vagus and glossopharyngeal nerves are located medially to it, and the capacity stimulates the adjacent vascular nerves, which is the anatomical basis for the symptoms caused by hypertelorism. Pathology of caudate hypertelorism There are several theories to explain the pathological changes of caudate hypertelorism: ① Partial or complete ossification of the caudate ligament. If part of the caudate develops into the caudate hyoid ligament, partial ossification of the ligament may cause caudate hyperechogenicity if there is an additional ossification center, and if the ligament is completely ossified, the caudate hyoid ligament ossifies (or calcifies) and heals bony with the hyoid tubercle, and a pseudarthrosis may form in the middle of the ossification. This theory is based on histologic evidence of chemotactic changes in the subperiosteum in the vicinity of the ligament attachment; and (3) retention of the cartilaginous component of the caudate attached to the temporal bone, which then ossifies into bone. Clinical manifestations of stem sinus hypertelorism The disease has a slow onset with a variable length of history, often with pain in the tonsillar region and tongue root region, often unilateral, mostly not severe, radiating to the ear or neck, and aggravated by swallowing. Foreign body or obstructive sensation in the pharynx is more common, mostly on one side, more pronounced when swallowing, sometimes aggravated during speech, head turning or at night. It can also cause coughing, and when the carotid artery is compressed or rubbed, the pain can radiate upward from one side of the jaw angle to the head and neck or face. Sometimes there may be tinnitus, salivation, insomnia and other signs of neurasthenia. Physical examination: hard striated or spiny protrusions can be palpated in the tonsillar region, and the patient may complain that this is a place of discomfort and may induce sore throat or aggravate sore throat. Most of them are unilateral and overgrown. Stromal radiographs often show excessive length, obliquity, or curvature. Diagnosis of hypertelorism Anyone over 20 years of age with sore throat, foreign body sensation, neck pain, ear pain, and headache should think of this disease and perform palpation and radiographs of the stoma. This disease should be differentiated from pharyngitis, glossopharyngeal neuritis, glossopharyngeal neuralgia, and stem fracture. Sometimes, even if the length of the stem is much longer than the standard length, but there are no symptoms, there is no need for surgery, sometimes the length of the stem does not reach the standard length, but the patient’s symptoms are obviously aggravated during the examination, we also choose surgery. The results are satisfactory. (Our radiological examination is mainly done by CT bone imaging, which can clearly visualize the angle and length of the stoma). In general, patients with no sensation or no significant sensation can be treated without surgery. Surgery should only be performed if the symptoms are severe and treatment is urgently needed. There are two surgical methods: transoral pharyngectomy and external cervical surgery (I mainly use transoral pharyngectomy). After surgery, the time and order of symptoms disappear varies. Generally, pharyngeal pain and foreign body sensation disappear faster, while headache, earache, tinnitus and dizziness sometimes disappear more slowly, and some take 1-6 months to disappear.