A 51-year-old woman with a five-month history of subacute thyroiditis, complicated by thyroid nodules and cysts, was successfully managed using a Liver-soothing, Phlegm-resolving, and Nodule-dissipating herbal strategy.

Case ID: CHC-0084

Case Summary

This case describes a 51-year-old woman who presented with severe anterior neck pain and swelling for five months. Despite prior hospitalization and a diagnosis of thyroid nodules, thyroid cysts, and subacute thyroiditis, her condition remained poorly controlled, with her thyroid function tests and inflammatory markers remaining abnormal. The original report documented a TCM assessment of Goiter/Thyroid Tumors (Ying Liu) driven by the intertwining of Phlegm, Dampness, and Blood Stasis, combined with Liver Qi Stagnation. She was managed by Professor Hu Shiping using a heavily modified combination of Xiao Ying Tang (Goiter-Eliminating Decoction) and Xianfang Huoming Yin (Sublime Formula for Sustaining Life) to physically break down the nodules, clear the inflammation, and restore the Spleen/Liver dynamic, resulting in a complete clinical and radiographic recovery.

Patient Presentation

• Patient: 51-year-old female (Surname: Gong).
• Main Complaint: Anterior neck pain and swelling for 5 months.
• History: The patient sought consultation on May 15, 2023. Five months prior, she developed unexplained anterior neck pain and swelling. She was hospitalized in an endocrinology department and diagnosed with thyroid nodules, thyroid cysts, and subacute thyroiditis. She felt the conventional treatment was ineffective, as her follow-up thyroid function and Erythrocyte Sedimentation Rate (ESR) failed to return to normal ranges.
• Associated Symptoms: The neck pain and swelling were accompanied by severe tenderness, which worsened significantly upon turning her neck or swallowing. She was easily irritable, experienced occasional restlessness, and suffered from paroxysmal left-sided migraines. The prolonged illness severely impacted her quality of life. She had no fever or abnormal sweating. Her appetite and bowel/urinary functions were normal.
• Physical Exam: Bilateral thyroid enlargement (Grade II). The glands were hard to the touch with distinct tenderness (+).

Examination and Diagnosis

• Imaging & Labs:
  • Thyroid Function: Free T3 (FT3) was elevated at 5.23 pg/mL; Free T4 (FT4) was elevated at 3.56 ng/mL; TSH was suppressed at 0.15 μIU/mL.
  • Inflammatory Markers: ESR was heavily elevated at 600 mm/h (noted as 60 mm/h in standard units contextually).
  • Ultrasound: Parenchymal echo changes in bilateral lobes (April 2023).
• Conventional Diagnosis: 1. Thyroid nodules; 2. Thyroid cysts; 3. Subacute thyroiditis.
• TCM Tongue and Pulse: The tongue body was dark red (舌暗红) with a thin, yellow, slightly thick coating. The pulse was stringy and slippery (脉弦滑).

TCM Assessment

The original practitioner interpreted the presentation as Goiter/Thyroid Tumor (Ying Liu) driven by the Intertwining of Phlegm, Dampness, and Stasis with Liver Qi Stagnation (瘿瘤 – 痰湿瘀互结，肝郁气滞).

According to the holistic principles of Chinese Medicine, classical surgical texts state that goiters and tumors “are not a swelling of Yin/Yang Righteous Qi, but are formed by the stagnation of the five Zang organs’ blood, turbid Qi, and phlegm.” Professor Hu Shiping considers Liver Qi Stagnation, Phlegm Coagulation, and Blood Stasis as the three critical elements of this disease.

In this patient, chronic stress or emotional frustration caused her Liver Qi to stagnate (leading to the irritability and migraines). Because the Liver failed to maintain smooth flow, it impaired the Spleen’s ability to transport fluids, generating Phlegm and Dampness. Over five months, this stagnant Qi and Phlegm obstructed the blood vessels in her neck, congealing into physical nodules and cysts (Stasis). The lack of superficial symptoms (like fever or floating pulse) indicated the pathogen had lodged deep into the collaterals. Her dark red tongue, yellow/thick coating, and stringy-slippery pulse provided textbook objective confirmation of this deep, trapped matrix of Phlegm, Damp-Heat, and Stasis.

Treatment Approach

The primary treatment principle was to eliminate phlegm and promote dampness, soothe the Liver and resolve stasis, soften hardness and dissipate nodules (祛痰利湿，疏肝化瘀，软坚散结). The strategy required a multi-target approach: regulating the Liver/Spleen to stop the production of phlegm and Qi stagnation, while aggressively using blood-moving and nodule-dissolving herbs to break down the existing physical masses.

Interventions and Herbal Formulas

• Initial Herbal Formula (May 15, 2023): A 17-herb decoction modifying Xiao Ying Tang (Goiter-Eliminating Decoction) and Xianfang Huoming Yin (Sublime Formula for Sustaining Life).
  • Clearing Heat, Softening, and Dissipating Nodules: Xia Ku Cao (Prunella, 30g) clears heat, calms the Liver, and dissipates nodules. Zhe Bei Mu (Fritillaria, 10g) and Zao Jiao Ci (Gleditsia Spine, 15g) aggressively transform deep phlegm and physically break down the cysts/nodules.
  • Soothing Liver, Moving Qi, and Resolving Stasis: Xiang Fu (15g) regulates Qi and soothes the Liver. Chuan Xiong (20g) moves Qi within the blood. Chuan Lian Zi (15g) stops the severe pain and drains trapped heat from the Liver channel. Zhi Ru Xiang (Prepared Frankincense, 10g), Zhi Mo Yao (Prepared Myrrh, 10g), and E Zhu (Curcuma, 10g) strongly break up the physical blood stasis, reducing the swelling and pain. Chi Shao (Red Peony, 20g) softens the Liver and cools the blood.
  • Drying Dampness and Fortifying the Spleen: Chen Pi (15g) and Fa Ban Xia (Pinellia, 15g) dry dampness and transform phlegm. Fu Ling (20g), Cang Zhu (15g), and Bai Zhu (15g) heavily fortify the Spleen to ensure fluid is metabolized, cutting off the source of the phlegm. Ze Xie (15g) drains the dampness and heat out through the urine. Gan Cao (5g) harmonizes the formula.
  • Administration: 14 doses, water decocted, taken warm after breakfast and dinner.

Follow-Up

• Outcome (July 2023): The patient returned to the clinic two months later for an unrelated issue (kidney stones). She happily reported that after taking the prescribed 14 doses, all of her previous thyroid symptoms (neck pain, swelling, migraines, irritability) had completely resolved and had not recurred.
• Clinical Confirmation: Follow-up laboratory tests showed her thyroid function (FT3, FT4, TSH) and Erythrocyte Sedimentation Rate (ESR) had completely returned to normal. Crucially, a repeat thyroid ultrasound showed that the thyroid nodules and cysts had entirely disappeared.

Why This Case Is Interesting (Clinical Reasoning)

The notable feature of this case is Professor Hu Shiping’s highly effective integration of internal medicine principles with external medicine (TCM surgery) strategies to treat a complex, treatment-resistant thyroid condition.

Subacute thyroiditis with nodules presents a challenge because it involves active inflammation (heat/pain), structural masses (phlegm/stasis), and systemic endocrine disruption. Rather than relying solely on anti-inflammatory or hormone-suppressing approaches, Professor Hu utilized Xianfang Huoming Yin—a famous classical formula for treating deep abscesses and toxic swellings—adapted with Xiao Ying Tang. By combining sharp, piercing herbs like Zao Jiao Ci and E Zhu to break the physical cysts, alongside a heavy Spleen-fortifying matrix (Cang Zhu, Bai Zhu, Fu Ling) to fix the metabolic root, the treatment perfectly addressed the “Phlegm-Dampness-Stasis” mechanism. This achieved a complete structural and functional cure of the thyroid in just two weeks of herbal therapy.

Source Original source: Shenzhen Hospital of Beijing University of Chinese Medicine (Longgang) / Traditional Chinese Medicine Bureau of Guangdong Province Original title: 【以案说医】胡世平：瘿瘤病因纷杂使，疏肝健脾散结蠲 Practitioner: Professor Hu Shiping (胡世平) Publication date: August 9, 2024 Original language: Chinese ChineseHerb.org version: English translation and editorial adaptation