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‘Complementary ENT’: a systematic review of commonly used supplements

  • P D Karkos (a1), S C Leong (a2), A K Arya (a1), S M Papouliakos (a3), M T Apostolidou (a4) and W J Issing (a5)
  • DOI:
  • Published online: 24 November 2006

To assess the evidence surrounding the use of certain complementary supplements in otolaryngology. We specifically focussed on four commonly used supplements: spirulina, Ginkgo biloba, Vertigoheel® and nutritional supplements (cod liver oil, multivitamins and pineapple enzyme).

Materials and methods:

A systematic review of the English and foreign language literature. Inclusion criteria: in vivo human studies. Exclusion criteria: animal trials, in vitro studies and case reports. We also excluded other forms of ‘alternative medicine’ such as reflexology, acupuncture and other homeopathic remedies.


Lack of common outcome measures prevented a formal meta-analysis. Three studies on the effects of spirulina in allergy, rhinitis and immunomodulation were found. One was a double-blind, placebo, randomised, controlled trial (RCT) of patients with allergic rhinitis, demonstrating positive effects in patients fed spirulina for 12 weeks. The other two studies, although non-randomised, also reported a positive role for spirulina in mucosal immunity. Regarding the use of Ginkgo biloba in tinnitus, a Cochrane review published in 2004 showed no evidence for this. The one double-blind, placebo-controlled trial that followed confirmed this finding. Regarding the use of Vertigoheel in vertigo, two double-blind RCTs and a meta-analysis were identified. The first RCT suggested that Vertigoheel was equally effective in reducing the severity, duration and frequency of vertigo compared with betahistine. The second RCT suggested that Vertigoheel was a suitable alternative to G biloba in the treatment of atherosclerosis-related vertigo. A meta-analysis of only four clinical trials confirms that Vertigoheel was equally effective compared with betahistine, G biloba and dimenhydrinate. Regarding multivitamins and sinusitis, two small paediatric pilot studies reported a positive response for chronic sinusitis and otitis media following a course of multivitamins and cod liver oil. Regarding bromelain (pineapple enzyme) and sinusitis, one randomised, multicentre trial including 116 children compared bromelain monotherapy to bromelain with standard therapy and standard therapy alone, for the treatment of acute sinusitis. The bromelain monotherapy group showed a faster recovery compared with the other groups.


The positive effects of spirulina in allergic rhinitis and of Vertigoheel in vertigo are based on good levels of evidence, but larger trials are required. There is overwhelming evidence that G biloba may play no role in tinnitus. There is limited evidence for the use of multivitamins in sinus symptoms, and larger randomised trials are required.

Corresponding author
Address for correspondence: Mr Peter D Karkos, Specialist Registrar in Otolaryngology, 36 Hopkinsons Court, Walls Ave, Chester CH1 4LN, UK. E-mail:
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1JC Dillon , AC Phuc , JP Dubacq . Nutritional value of the alga Spirulina. World Rev Nutr Diet 1995;77:3246

3RA Kay . Microalgae as food and supplement. Crit Rev Food Sci Nutr 1991;30:555–73

4HN Yang , EH Lee , HM Kim . Spirulina platensis inhibits anaphylactic reaction. Life Sci 1997;61:1237–44

5TK Mao , J Van de Water , ME Gershwin . Effects of a Spirulina-based dietary supplement on cytokine production from allergic rhinitis patients. J Med Food 2005;8:2730

7T Hirahashi , M Matsumoto , K Hazeki , Y Saeki , M Ui , T Seya . Activation of the human innate immune system by spirulina: augmentation of interferon production and NK cytotoxicity by oral administration of hot water extract of Spirulina platensis. Int Immunopharmacol 2002;2:423–34

9E Ernst , C Stevinson . Ginkgo biloba for tinnitus: a review. Clin Otolaryngol Allied Sci 1999;24:164–7

11S Drew , E Davies . Effectiveness of Ginkgo biloba in treating tinnitus: double blind, placebo controlled trial. BMJ 2001;322:16

12D Rejali , A Sivakumar , N Balaji . Ginkgo biloba does not benefit patients with tinnitus: a randomized placebo-controlled double-blind trial and meta-analysis of randomized trials. Clin Otolaryngol Allied Sci 2004;29:226–31

13LA Linday , JN Dolitsky , RD Shindledecker . Nutritional supplements as adjunctive therapy for children with chronic/recurrent sinusitis: pilot research. Int J Pediatr Otorhinolaryngol 2004;68:785–93

14LA Linday , RD Shindledecker , JN Dolitsky , CE Pippenger . Lemon-flavoured cod liver oil and a multivitamin-mineral supplement for the secondary prevention of otitis media in young children: pilot research. Ann Otol Rhinol Laryngol 2002;111:642–52

16M Weiser , W Strösser , P Klein . Homeopathic vs conventional treatment of vertigo: a randomized double-blind controlled clinical study. Arch Otolaryngol Head Neck Surg 1998;124:879–85

18W Issing , P Klein , M Weiser . The homeopathic preparation Vertigoheel versus Ginkgo biloba in the treatment of vertigo in an elderly population: a double-blinded, randomized, controlled clinical trial. J Altern Complement Med 2005;11:155–60

19E Ernst . Herbal medicines: where is the evidence? BMJ 2000;321:395–6

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