on October 27, 2026
The upper respiratory tract and the boundary between symptom and disease
Sore throat, nasal congestion, secretions, cough, facial pain, and ear pain are very common manifestations of upper respiratory tract infections. In most cases, the starting point is a viral infection, while a smaller proportion of pharyngeal and rhinosinusitis cases are caused by bacteria.
This distinction is also fundamental when considering a phytotherapeutic approach. A herbal remedy can play a role in symptomatic relief, supporting the body's response, or, for some standardized preparations, reducing the duration of certain conditions. However, this does not mean that every plant has clinically proven antimicrobial activity or that it can replace pharmacological treatment when indicated.
The principle of integrated medicine should therefore be one of complementarity: use what has biological plausibility and an adequate level of evidence, without losing sight of diagnosis, severity, the patient's age, and the risk of complications.
Pharyngitis: first distinguish viral forms from bacterial ones
Pharyngitis mainly manifests as pain or burning in the throat and pain during swallowing; fever, headache, and general malaise may also occur. Viral infections are the most frequent cause.
A different situation is that of streptococcal pharyngitis. When a group A streptococcal infection is present, the diagnosis must be made through an appropriate clinical assessment and, when indicated, by microbiological tests. Antibiotic treatment of confirmed or strongly suspected cases according to guidelines must not be replaced by phytotherapy, because the goal is not only to reduce a sore throat but also to prevent complications and the transmission of the infection.
In this context, medicinal plants can be considered primarily for symptom control, for example for irritation and dryness of the mucosa.
Echinacea: a possible support, but not all preparations are equivalent
Echinacea is probably one of the most studied plants in the context of respiratory infections. The genus includes different species, including Echinacea purpurea, Echinacea angustifolia, and Echinacea pallida, and commercial preparations may use roots, aerial parts, juices, or extracts obtained with different solvents.
This variability is essential because it is not correct to consider echinacea as a pharmacologically uniform product.
Clinical reviews have produced results that are not completely consistent. A Cochrane review highlighted that the available studies used very different preparations and that the overall effect on the prevention and treatment of the common cold remained uncertain and, when present, generally modest.
A more recent meta-analysis, published in 2025 and dedicated in particular to children, found favorable signs for some preparations of Echinacea purpurea, with a reduction in the duration and incidence of upper respiratory tract infections. Interesting results also emerged for the recurrence of otitis media, while the effect on the duration of an episode of otitis was not significant. However, the authors highlighted the strong heterogeneity of the preparations and the need for further studies.
The most cautious conclusion is therefore that some echinacea extracts may have a favorable effect on respiratory infections, but the results cannot be automatically extended to all species, all extracts, and all dosages.
From a safety standpoint, echinacea is generally well tolerated, but allergic reactions are possible, especially in individuals sensitized to Asteraceae. Precautions in people with immunological conditions, on immunosuppressive therapy, or during pregnancy require an individual assessment.
Eucalyptus: primarily a symptomatic role
Eucalyptus, particularly the essential oil rich in 1,8-cineole, is traditionally used for respiratory disorders. Its pharmacological activities have been studied mainly in relation to the modulation of respiratory tract inflammation and the thinning of secretions.
However, it is important to distinguish the data obtained with isolated 1,8-cineole from studies conducted with genuine eucalyptus essential oil. The EMA considers eucalyptus essential oil a traditional remedy for the relief of cough associated with the common cold, stating that its efficacy is supported mainly by long-standing experience of use and not by sufficient clinical evidence to speak of established efficacy.
The use of essential oil also requires particular attention. Oral intake is not appropriate for young children, and preparations containing eucalyptus have specific contraindications in children with a history of seizures. There is also a risk of laryngospasm in very young children.
For this reason, “natural” does not automatically mean “safe”. Essential oils are concentrated substances, and their use must respect the formulation, route of administration, age, and product indications.
Erysimum: phytotherapeutic tradition for the throat and voice
Sisymbrium officinale, known as erysimum or “singer’s herb,” is traditionally used for throat irritation, hoarseness, and dry cough.
The EMA recognizes a traditional use for this plant, meaning one based mainly on long-standing experience of use and not on a level of clinical evidence comparable to that required for an established therapeutic indication.
Its interest therefore concerns mainly the relief of pharyngeal mucosa irritation and the alleviation of voice disorders.
This is an important example of how phytotherapy should be correctly interpreted: a plant can have a recognized traditional indication without this being equivalent to the demonstration of pharmacological efficacy through large randomized studies.
Sinusitis: the problem is not just “drainage”
Rhinosinusitis involves inflammation of the nasal mucosa and paranasal sinuses. It can occur during a viral infection and, in a minority of cases, evolve into a bacterial form.
In clinical practice, it is therefore essential to distinguish common viral rhinosinusitis from a persistent or complicated bacterial form. The most recent guidelines emphasize the importance of avoiding the indiscriminate use of antibiotics and resorting to a progressive clinical assessment, paying particular attention to the duration and course of the symptoms.
Phytotherapy can be incorporated mainly into symptom management. A systematic review and a network meta-analysis comprising 47 randomized studies on 18 phytotherapeutic preparations highlighted favorable results for some specific formulations, including Pelargonium sidoides and preparations based on cineole, especially in cases of the common cold and post-viral rhinosinusitis. However, the certainty of the evidence varied depending on the pathology and the preparation studied.
Randomized clinical studies have also observed an improvement in acute rhinosinusitis symptoms with some standardized preparations of Pelargonium sidoides.
A more recent review of essential oils also found favorable results in several randomized studies on acute rhinosinusitis, but with important differences between preparations, routes of administration, and measures of efficacy.
These data suggest a fundamental concept: there is no generic “phytotherapy for sinusitis,” but rather specific herbal preparations that must be evaluated individually.
Verbascum and Agrimonia: biological interest, clinical evidence still limited
Verbascum thapsus, known as common mullein, contains mucilage, saponins, flavonoids, and other bioactive compounds that may explain an emollient and anti-inflammatory activity on the mucosae.
Agrimonia eupatoria, on the other hand, contains tannins, triterpenes, and flavonoids and is traditionally used for mucosal irritation and respiratory tract conditions.
However, for both plants, the transition from pharmacological plausibility or traditional use to clinical efficacy in sinusitis is not sufficiently documented by large randomized studies. They should therefore be considered plants of phytotherapeutic interest, without attributing to them a therapeutic efficacy for sinusitis that clinical literature has not yet adequately demonstrated.
It is precisely this distinction between biological mechanism, traditional use, and clinical outcome that allows for a truly scientific approach to phytotherapy.
Chamomile and inhalations: attention also to safety
Chamomile is traditionally used for its soothing effect and for topical use on the mucosae. The reference text proposes the use of steam inhalations to promote relief of sinus symptoms.
Today, however, the inhalation of very hot steam must be evaluated with caution, especially in children, due to the risk of burns. It is not necessary to resort to high temperatures to obtain symptomatic benefit, and temporary relief of congestion should not be confused with the treatment of the cause of sinusitis.
For the management of nasal congestion, saline irrigations represent a widely used non-pharmacological approach and are included in symptomatic strategies for rhinosinusitis.
Otitis: phytotherapy must not delay diagnosis
Otitis represents an even more delicate chapter. Ear pain can be caused by different conditions and, especially in children, it is necessary to distinguish acute otitis media from otitis media with effusion and from other ear pathologies.
Acute otitis media can be viral or bacterial and, in children, it often tends to resolve spontaneously. NICE guidelines emphasize that most children improve within a few days without antibiotics; however, some subgroups and more severe forms may require antibiotic therapy and medical assessment.
This means that phytotherapy may eventually have a supportive role, but it must not be used to avoid medical assessment when the pain is severe, high fever appears, there is ear discharge, the condition worsens rapidly, or the patient is particularly young or frail.
Even more important is the case of otitis media with effusion: in this condition antibiotics are not recommended, and neither phytotherapy nor other unsupported treatments should be used automatically. Management depends mainly on the duration of the effusion, any hearing loss, and the impact on the child.
The value of phytotherapy depends on the preparation
One of the main errors when talking about medicinal plants is to consider the plant as if it were a single active ingredient.
In reality, substantial differences can exist between a tincture, a dry extract, a standardized extract, an herbal tea, and an essential oil in terms of composition, concentration, bioavailability, and safety.
The same applies to echinacea: clinical studies cannot be automatically transferred from one preparation to another. Systematic reviews have precisely highlighted this heterogeneity as one of the main obstacles to the interpretation of results.
For a truly scientific integrated medicine, therefore, the correct question should not simply be:
“Does this plant work?”
but:
“Which preparation, at what dose, in which patient, for which condition, and with what level of evidence?”
Prevention: not only plants, but biological soil and behavior
The prevention of respiratory infections cannot be entrusted to a single phytotherapeutic product.
Reducing exposure to tobacco smoke, avoiding highly polluted environments, maintaining adequate hydration, improving indoor air quality, and addressing predisposing conditions, such as allergic rhinitis and impaired nasal ventilation, play a more general role.
Diet, sleep, physical activity, and maintaining good immune function are also part of a comprehensive approach to respiratory health.
In this scenario, phytotherapy can represent one of the available tools, not necessarily the main one, and certainly not a substitute for diagnosis.
When it is necessary to consult a doctor
Sore throat, nasal congestion, and cough are often self-limiting conditions, but some signs require a clinical assessment.
It is advisable to consult a doctor in the presence of difficulty breathing or swallowing, very intense pain, persistent or high fever, worsening after an initial improvement, symptoms lasting beyond the normal course, ear discharge, severe ear pain, swelling of the face or the area around the eyes, visual changes, neck stiffness, confusion, or immunosuppression.
In children, the threshold for attention must be even lower.
Phytotherapy is most useful when placed in the right place: as a possible support, chosen on the basis of evidence and safety, within a broader diagnostic and therapeutic strategy.
Evidence-based phytotherapy
The growing interest in medicinal plants must not lead either to a prejudiced rejection of phytotherapy or to the opposite conviction that everything natural is effective and risk-free.
The available evidence shows a complex picture. Some echinacea preparations show interesting clinical results in respiratory infections; some herbal formulations have been studied in rhinosinusitis with favourable results; eucalyptus retains indications mainly for traditional use; elecampium is recognised for traditional relief of throat irritation. At the same time, for many other plants, clinical evidence remains insufficient.
A recent overview of systematic reviews on herbal medicines in respiratory infections confirmed this very picture: some remedies show modest benefits, but the heterogeneity of the studies and methodological limitations prevent strong recommendations for most preparations.
The future of respiratory phytotherapy therefore lies in the standardisation of extracts, the definition of doses, the pharmaceutical quality of preparations, and adequately sized randomised clinical trials.
This is the step that allows integrative medicine to move beyond mere tradition and build a model in which user experience, pharmacology, safety, and clinical evidence can interact.
PLEASE NOTE
The information provided is for informational and educational purposes and does not constitute medical advice, nor does it replace a doctor's assessment, diagnosis, or prescription of a treatment. Herbal remedies should not automatically be considered alternatives to prescribed medications. In the presence of bacterial infections, complications, serious symptoms, or particular conditions, a medical assessment is necessary. The use of medicinal plants, and especially essential oils, must take into account age, pregnancy, allergies, concomitant conditions, pharmacological treatments, and specific preparation methods.
Bibliography
1. Karsch-Völk M, Barrett B, Kiefer D, Bauer R, Ardjomand-Woelkart K, Linde K. Echinacea for preventing and treating the common cold. Cochrane Database Syst Rev. 2014;2.
2. Pham TT, et al. Efficacy and safety of Echinacea purpurea in treating upper respiratory infections and complications of otitis media in children: Systematic review and meta-analysis. Clin Nutr ESPEN. 2025;67:702-713.
3. Hoang MP, et al. Herbal Medicines for Rhinosinusitis: A Systematic Review and Network Meta-analysis. Curr Allergy Asthma Rep. 2023;23.
4. Treatment of acute rhinosinusitis with the preparation from Pelargonium sidoides EPs 7630: a randomized, double-blind, placebo-controlled trial. PubMed PMID: 19382496.
5. Effects of Essential Oils in the Treatment of Acute Rhinosinusitis: A Systematic Review. 2025. PubMed PMID: 40575453.
6. European Medicines Agency. Eucalypti aetheroleum – European Union herbal monograph. EMA/HMPC.
7. European Medicines Agency. Sisymbrii officinalis herba – European Union herbal monograph. EMA/HMPC/280193/2013.
8. Payne SC, et al. Executive Summary of the Clinical Practice Guideline on Adult Sinusitis Update. Otolaryngol Head Neck Surg. 2025.
9. NICE. Otitis media (acute): antimicrobial prescribing. Guideline NG91. Updated 2022.
10. NICE. Otitis media with effusion in under 12s. Guideline NG233.
11. Review and Assessment of Medicinal Safety Data of Orally Used Echinacea Preparations. PubMed.
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