Journal of Otolaryngology-ENT Research
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Volume 8 Issue 2 - 2017
ENT and Phoniatrician, Private Practice, Italy
Orietta Calcinoni, ENT and
Phoniatrician, Private Practice, Via Mac Mahon, Italy, 19, Tel:
0039 3482247244; Email:
June 24, 2017 | August 09, 2017
J Otolaryngol ENT Res 2017, 8(2): 00243
is a plant used since Greeks Medicine in vocal tract
diseases to reduce disability derived from dryness, sore throat, cough,… Modern
Phytopharmacology is standardizing active principles in this plant, but still few works
in literature describe results known in traditional medicine.
A small group of patients treated with Sisymbrium at recommended doses described
the perceived physical disability pre and post treatment by VHI (Voice Handicap
Index) scores. Analysis of the difference (delta) between VHI scores seems to prove
way Sysimbrium results a choice to solve patients’ discomfort, reserving “classical”
treatments - NSAIDs and antibiotics - to major pathologies.
Keywords: Vocal tract; Erysimum; ; VHI; Phytotherapy
Sisymbrium is an annual plant, spread mostly in the Eurasiatic
Region and North Africa. It is very common in bare ground, on
North America, too. There are many types of Sisymbrium: the
most used in vocal tract diseases is (L.)
The huge amount of popular nouns given to it (Table 1)
“catharral” diseases: indeed this millennial belief has but a few
Botanical Name (*from an
Botanical Synonim (L.)
Herba/Semen Sisymbrii (= Herba/Semen
Greek : I save sing
Italian Erba cornacchia comune
Erba dei cantanti
English Hedge mustard
French Herbe aux chantre
Hierba de los cantores
Hierba de San Alberto
Dioscoride recommended it in “catharralis” diseases, so also in
jaundice and in poisoning. In the XVII century, Jacques Dalechamps,
author of Historia generalis plantarum, wrote that his master
Guillaume Rondelet “professeur royal de médecine à Montpellier”
gave it to a young choir singer, who promptly regained his voice.
Fernie  cited that, up to the time of Louis XIV, Racine wrote to
Boileau to recommend him Erysimum syrup in order to be cured
of voicelessness :“Si les eaux de Bourbonne ne vous guerissent pas
de votre extinction de vois, le syrop d’Erysimum vous guerirait
infalliblement. Ne l’oubliez pas, et a l’occasion vingt grammes par
liter d’eau en tisane matin et soir“. Tradition says that Racine gave
this advice because he knew a singer, voiceless since 6 months,
helped by erysimum to regain his voice and sing in front of the
King in Notre Dame Cathedral.
In the International Plant Name Index 1, the plant name was
given in 1772 by Giovanni Antonio Scopoli . He wrote it in
Flora Carniolica, a book to describe plants of his region (now in
Northern Italy, between Trentino and Friuli regions). Scopoli was
called “the Linnaeus of the Austrian
Empire”: indeed he and Linnaeus were corresponding and
Linnaeus named a solanaceous genus, Scopolia, the source of
scopolamine, after him.
Traditional medicine recommends using the semi-fresh
in order to prepare
an infusion having therapeutic effects to treat sore throats, coughs,
and hoarseness (Benigni, et al. . In his main text (1995) Font-
la ronquera, así como contra la tos, los catarros pulmonares, etc.,
amen del escorbuto. Se usa de preferencia la planta fresca. Con la
hierba recién colectada se prepara una tisana, como si se tratara de
te, es decir, poniendo a hervir un cacito de agua y echando en ella
cosa de 1 onza de la planta, tallos y hojas, por cada cuatro tazas; se
toma cuando queda templada, y después de echar el azúcar que se
of the larynx, especially to combat hoarseness, as well as against
cough, pulmonary catarrh, etc., and scurvy too. The fresh plant is
preferably used. The freshly harvested herb is prepared, as if it
were tea, that is, putting a boil of water and throwing in it 1 ounce
of the plant, stems and leaves, for every four cups; is taken when it
is tempered, after pouring the desired sugar “.
The chemical markers of are sulphated
compounds, particularly glucosinolates, isothiocyanates and
sulphated lactones, also found in mustard oil ; the main
glucosinolate is glucoputranjivine . Historically, the sulphated
compounds are reputed to stimulate the mucosal secretion in the
upper respiratory tract, so increasing expectoration .
(= ) contain respectively 3: 0.63% to 0.94%
glucosinolates -where a minimum of 0.3% of total glucosinolates
is expressed as sinigrin (C10H16KNO9S2; Mr397,5) and up to
a 65% is isopropyl- glucosinolate -, 10.9% to 13.5% mucilages,
In the semen: cardenolide glycosides [8,9]. Essential
oil: glucosinolates; thiocyanic glycoside. In the fresh
(3-butenylglucosinolates) ascorbic acid (216.5 mg/100 g in
fresh foliage) . The tips of the foliage include among others
corchoroside A (18.5 mg/100 g) and helveticoside (4.5 mg/100
g), cardioactive steroid glucosides.
Acqueous dried extract shows absence of sinigrin and presence
of glucoputranjivin, isopropyl isothiocyanate and proline;
putranjivine resulted to be 0.5 mg/g , adenine, 3 Calculated
for the dried herbal substance  adenosine, and guanosine were
aqueous extract .
Volatile compounds of hedge mustard ()
after hydrodistillation (without or upon autolysis) with gas
chromatography/mass spectrometry analyses .
The Community herbal monograph refers only to two herbal
herbal substance and dry extract - extraction solvent ethanol 50%
(V/V - volume to volume-) or water. The herbal substance is also
available in combination products with other herbals or chemical
substances, mainly codeine or sulfoguajacol and other herbal
The pharmacological activity of Sisymbrium shows anti-
spectrum antimicrobial properties .
adenosine, guanine and oligosaccharides. They tested topical
ear edema model but only a modest effect was observed at high
Eccles hypotesized a generic “placebo-like” relaxing effect from
sweet gustatory perception: gustatory afferences are mediated by
localized in the rostral part of nucleus of solitary tract (NTS), so
cough center is partially overlapped by gustatory afferences and
sweet taste releases opioid peptides in NTS inhibit cough stimuli.
But this effect should derive from sweeteners added to erysimum,
which is a bitter plant.
European Medicines Agency (EMA) monograph “Assessment
report on (L) Scop. herba” states that
period of at least 30 years as requested by Directive 2004/24/
EC (European Community), thus the requirement for the
(long-standing use) in the following indication: traditional
herbal medicinal product for the relief of throat irritation such
as hoarseness and dry cough. Since clinical studies with products
containing hedge mustard have not been found in the literature
well-established use cannot be recommended. The mitigating
effect of the herbal substance on the pharyngeal irritation might
be due to the high mucilage’s content (10.9%-13.5%) . The
several combination products were on the market in Spain which
included Erysimum Flos combined with Liquiritiae radix, Althaea
radix, Marrubii herba, Anisi fructus and/or Thymi herba. For
example in Euphon® syrup and pastille until 2004 in Belgium.
Regulatory status overview: Marketing Authorisation only in
Belgium and Portugal while Traditional Use Registration only in
Germany and France. On the counter product in other countries.
As far as now, there are no known or proved side effects
for Sisymbrium. The reported pharmacological effects are not
pharmacokinetics and interactions are not available.
of could not be retrieved. However, during
the long-standing use in the Member States, no adverse effects
or incidences were reported (Wolf 1992). Based on this it is
concluded that there are no safety concerns relating to the use of
the preparations in the given indication at the traditionally used
2014 EMA monograph generally indicates contraindication
in traditional use “in case of hypersensitivity to the active
special warnings and precautions for use, recommend to avoid
oromucosal use under 6yrs “because of the pharmaceutical
of a German product shows “The use in children under 5 years
of age is not recommended due to lack of adequate data.”) The
children under 3 years of age and oral use under 3yrs , due to lack
of adequate data and because medical advice should be sought.”
No fertility data available nor about genotoxicity. Safety during
pregnancy and lactation has not been established, even if the
not contraindicated during pregnancy and lactation.” while in the
No studies on the effect on the ability to drive and use machines
have been performed. No undesirable effects known.
About pharmaceutical particulars, the content of cardenolides
vomiting, diarrhoea, headache and cardiac rhythm disorders have
been reported.” It is conceivable that over dosage would have
digitalis-like effects. These should include queasiness, vomiting,
diarrhoea, headache and cardiac rhythm disorders , PDR for
Herbal Medicines . Cases of poisonings, however, have not been
glycosides”. EMA report comments: This is only a theoretical
assumption; no report is mentioned in the market overview. So
no data available about pharmaceutical interactions.
Ema’s overall conclusions on ’s
a) The medicinal use of hedge mustard preparation is considered
safe because no adverse effects have been reported during
the long-standing use as a medicinal product in Belgium and
b) The known toxic cardioactive steroid glycosides have been
documented as a minor component and their concentrations
are too low to present any risk to human health.
c) The oromucosal use in children under 6 years of age is not
recommended because of the solid dosage form and due to
lack of adequate data.
d) The oral use in children under 3 years of age is not
recommended due to lack of adequate data and because, for
the proposed indication, medical advice should be sought for
this age group.
and lactation is not recommended.
Aim of the Study
The vocal tract needs a high level of hydration to work
properly, mostly at vocal folds edges level. The risk for friction and
its derived lesions is directly related to relative humidity, amount
The aim of this work is to observe perceived vocal tract
disability and its variation after a short treatment with Sisymbrium
. As to World Health Organization, the consequences
handicap. Disability is described as “a restriction or lack of ability
as, “a social, economic, or environmental disad-vantage resulting
from an impairment or disability.”.
A widespread used method to assess perceived Voice Handicap
is Vocal Handicap Index questionnaire (VHI) by Jacobson et
al. , where handicap is measured through three different
scales measuring Physical, Functional and Emotional perceived
disabilities. Perception of dryness and sore throat in the vocal
tract is physically disabling. The scores delta, between pre and
post treatment, in Physical Scale of VHI has been chosen to
describe the perceived reduction in vocal tract disability.
Materials and Methods
Only France and Germany have products registrated for
traditional use . In this work the Authors used French product
Sisymbrium. In random serie, patients claiming vocal tract
discomfort were treated with Sisymbrium, 90 mg extract/day for
10-20 days,  alone or with treatment related to the diagnosed
Diagnosis was described as: Functional Dysphonia (FD),
Upper Airways Acute Flogosis (UAAF) or Upper Airways Chronic
Flogosis (UACF), obtained through ENT objective evaluations. We
tried to plan a “placebo control group”, but the pharmaceutical
The Patients were 64 F and 40 M, aged 8-80 yrs -mean age
42,1yrs. They were 65 artists (A), 30 non artists (NA) and 9 Voice
Professionals in spoken non artistic voice (VP). 3 of them did not
submit to controls (NA) so the studied group was of 62 F, 39 M; 63
A, 30 NA, 8 VP. Their diagnosis distributed as 20 FD, 21 OD, 5 LPR,
14 LPR + OD, 32 UAAF, 13 UACF.
i. The mean VHI-P pretreatment score was 27, 9 /40: pretty high
level of perceived disability. The mean VHI-P post treatment
score was 13, 2: a very low level of residual disability.
ii. The average DELTA VHI was around 14/40: this means the
reduction of one third of the perceived disability in a short
iii. In FD the treatment with Sisymbrium obtained a mean
reduction of disability of 13/40.
iv. In OD the result was 13, 6/40 in Sisymbrium alone treatment,
while in 10 days complex treatment the reduction was 13/40
and in 20 days 14, 4/40.
v. In LPR the treatment with added Sisymbrium gave a mean
reduction of 12/40 in a 10 days treatment and 13, 9/40 in a
20 days treatment.
vi. In UAAF treated with Sisymbrium the mean perceived
reduction was 15/40, 14, 9/40 in 10 days combined and 15,
6/40 in 20 days combined.
vii. In UACF treated with Sisymbrium plus FANS for 20 days, the
referred reduction of perceived disability was 13, 2/40 avg.
effects in terms of edema reduction in mice ears (inners faces
of auricular pavillon) measured as weight reduction of treated
samples meaning edema’s reduction. This choice might have
effect does not look similar to NSAIDs, like salycilates [18-20].
In our work the main claim is physical disabling effect of
dryness, related to hyperemia and sticky secretions. The effect of
Sisymbrium seems mostly “moisture enhancing”, - and in this case
tissues’ weights should not change that much, or better increase
The scores show a homogenous reduction around 30%
(13/40) of perceived disability. The scores seem independent
from different diagnosis or single or combined treatment. So the
presence of Sysimbrium in the treatment seems the common
factor facilitating reduction of perceived disability.
Vocal tract pathologies must be treated following Evidence
Based Medicine protocols. But Biagi  pointed out that in some
cases Phytoterapy mantains a pivotal role in the modern EBM.
“Main peculiar features of medicinal plants may be compared to
b. Multitarget mechanism of action
c. Synergistic mechanism of phytocomplex”
In our work a small group of patients with different diseases
of the vocal tract, all resulting in perceived physical disability, a
observation seems coherent to traditional medicine expectations
So we conclude that, in diagnosed absence of major diseases,
when in a Patient the desired effect is simply prompt reduction
of perceived disability to reduce resulting handicap, if prescribed
under physician control and instrumental assessment, monitoring
subjective perception of symptoms, phytotherapy may show
may be expensive, redundant or present undesired side effects.
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