bubble_chart Concept

The swelling in the submandibular and anterior cervical regions, on both sides of the laryngeal prominence, is referred to as cervical swelling.

Throughout history, medical practitioners have classified cervical swelling under the categories of goiter or hyperthyroidism. Since it occurs on both sides of the laryngeal prominence, it is also known as "Xia Ying" (Lingshu．Jingmai chapter). The term "Ying" mentioned in the "Classic of Mountains and Seas" also refers to goiter. Based on historical records, it can generally be divided into two situations: one is regional cervical swelling, which occurs in a specific area and affects both the young and old, such as the "Ju Ying Country" mentioned in the "Classic of Mountains and Seas"; the other is non-regional cervical swelling, which mostly occurs in young people, particularly women. The former, aside from cervical swelling, does not present significant systemic symptoms, while the latter often includes more noticeable systemic symptoms. This condition primarily refers to the latter.

This condition differs from cervical swelling caused by scrofula, cervical malignancy with cachexia, and suppurative parotitis. Scrofula and cervical malignancy with cachexia occur on the sides of the neck, under the jaw, or behind the ears, and the swellings are hard and often connected in clusters. Suppurative parotitis occurs under the jaw, has a rapid onset and short duration, and is accompanied by symptoms such as redness, swelling, heat, and pain. In contrast, this condition has a gradual onset, with soft swellings typically occurring on both sides of the laryngeal prominence, which are slightly tender to touch and can move up and down with swallowing.

bubble_chart Pattern Analysis

1. Phlegm and Qi Stagnation︰Diffuse swelling on one or both sides of the Adam's apple with indistinct margins, normal skin color, soft upon palpation, painless, or with a grade I sense of distension, often accompanied by chest tightness, hypochondriac pain or distension, irritability, white or greasy tongue coating, and wiry or slippery pulse. This is caused by phlegm accumulation, where qi movement is obstructed, and water-dampness fails to transform into body fluids, condensing into phlegm. It must manifest phlegm-related symptoms (thick neck with diffuse swelling, soft upon palpation, painless or slightly painful, distension, white or greasy tongue coating, wiry or slippery pulse). Treatment should focus on moving qi and clearing phlegm to resolve stagnation, using formulas such as Sihai Shuyu Pill or Sargassum Jade Flask Decoction with modifications.
2. Qi Stagnation and Blood Stasis︰The anterior neck is significantly swollen and enlarged, with a slightly firm texture due to prolonged illness, accompanied by distension or grade I pain upon pressure. The skin remains unchanged or exhibits visible red streaks, with difficulty in breathing or a sensation of swallowing obstruction. Symptoms include chest tightness, hypochondriac pain, irritability, a dark tongue texture, and a deep, choppy pulse. Over time, signs of static blood coagulation become evident (marked neck swelling, firm and painful upon pressure, purplish-dark tongue or ecchymosis, and a deep, choppy pulse). Treatment should focus on regulating qi and resolving stasis to dissipate blood stasis, using the blood-invigorating and stasis-resolving decoction.
3. Heart and Liver Yin Deficiency︰The neck may be swollen to varying degrees or not significantly enlarged, but symptoms of liver yin deficiency are prominent, including palpitations, flusteredness, restlessness and insomnia, spontaneous sweating, shortness of breath, as well as irritability, dizziness, blurred vision, and protruding eyes with a dry sensation. In severe cases, there may be vexing heat in the chest, palms, and soles; facial flushing; night sweats; soreness and weakness in the lower back and knees; finger tremors or spasms; or in men, nocturnal emission or spermatorrhea; in women, menstrual irregularities; a red tongue with scant coating; and a wiry-rapid or thin-rapid and weak pulse. Although neck swelling is caused by phlegm accumulation or blood stasis, which are tangible excess pathogens, once neck swelling is clinically observed, the disease has already persisted for a long time, and healthy qi has become deficient, manifesting as heart and liver yin-blood deficiency. Insufficiency of heart yin leads to palpitations, restlessness, easy fright, insomnia, low-grade fever, spontaneous sweating, and shortness of breath; liver yin deficiency results in irritability, dizziness, blurred vision, protruding and dry eyes, and even tremors or spasms in the hands and feet, vexing heat, night sweats, and lower back soreness. Treatment should focus on enriching yin and replenishing blood, supplemented with herbs to soften hardness and dissipate masses. The recommended formulas are Four Ingredients Decoction combined with All-Along Decoction, or Liver-Tonifying Decoction with additions such as oyster shell, clam shell, kelp, and seaweed.

The formation of phlegm qi depression and blood stasis in the neck is primarily due to liver depression qi stagnation. Therefore, both conditions exhibit clinical manifestations of liver qi stagnation (such as chest tightness, hypochondriac pain, irritability, dizziness, etc.). Clinically, it is more common to see cases where qi stagnation, phlegm coagulation, and blood stasis coexist, known as concurrent phlegm and stasis. Hence, the common treatment methods include moving qi to break stagnation, softening hardness to dispel phlegm, and invigorating blood to resolve stasis. For moving qi, herbs like green tangerine peel, dried tangerine peel, cyperus, immature orange fruit, aucklandia root, and citron fruit are often used. For dispelling stasis, herbs such as salvia, red peony root, frankincense, myrrh, sparganium rhizome, zedoary rhizome, sappan wood, and leech are selected. To soften hardness, substances like oyster shell, ark shell, fritillaria bulb, kelp, seaweed, and sea clam shell are used. Initially, neck swelling due to phlegm and blood stasis may present as an excess pattern, but over time, it can transform into a deficiency-type pathogen. Therefore, while attacking the pathogen, one must also consider the healthy qi.

In summary, neck swelling can be either an excess pattern or a complex pattern of deficiency and excess. When caused by phlegm and blood stasis, it may start as an excess pattern but can become a pattern of deficiency and excess complex over time. Neck swelling due to heart and liver yin deficiency is a complex pattern of deficiency and excess. Treatment may involve expelling phlegm or attacking stasis, as stated in Suwen．Zhizhenyao Da Lun: "Hardness should be whittled, exogenous pathogen should be expelled, ... treating pathogenic accumulation with dissipation, treating retention with purgation," to expel the excess pathogen, or nourishing the yin of the heart and liver to address the deficiency.

bubble_chart Documentation

1. "Dong Tian Ao Zhi: Goiters and Tumors": "There are three types of goiters: one is blood goiter, one is fleshy goiter, and one is qi goiter. Blood can be broken, flesh can be cut, and qi can be punctured. In fact, all three types should be treated internally, not externally."