European Annals of Otorhinolaryngology, Head and Neck diseases (2011) 128, 133137

REVIEW OF THE LITERATURE

Honey in otorhinolaryngology: When, why and how?

A. Werner , O. Laccourreye
Universit Paris-Descartes, Service doto-rhinolaryngologie et de chirurgie cervicofaciale, hpital europen Georges-Pompidou,
Assistance publiquehpitaux de Paris, 2040, rue Leblanc, 75015 Paris, France
Available online 9 February 2011

KEYWORDS
Honey;
Otorhinolaryngology

Summary In this review of the literature devoted to the use of honey, the authors analyse the
composition, indications, benets and adverse effects of this product in otorhinolaryngology
and head and neck surgery. Published data indicate that honey applied topically to skin and
mucosal wounds and/or burns and administered orally as antitussive medication (after the rst
year of life) is highly effective with no adverse effects. The physiological action of honey is
the result of various mechanisms (osmotic, detersion, bactericidal action). Various medicinal
honeys are available worldwide, but only one has Food and Drug Administration approval for
the treatment of wounds. After the rst year of life, the use of food honey appears to be as
effective as medicinal honey, while decreasing the overall cost of treatment.
2011 Elsevier Masson SAS. All rights reserved.

Introduction
Religious texts describe honey as a great gift to mankind
(Table 1) and honey has been used for medicinal purposes
for more than 4000 years [1]. Sumerian tablets dating from
2100 B.C. describe the use of honey in various recipes and
dressings [1]. About 500 remedies are also described in
the Smith, Ebers and Kahum papyruses written in Egypt
between 2000 and 1000 B.C. [1]. In India, at the same period,
Ayurvedic physicians considered that honey acted on the
essential elements (air, re, bile and circulation) that determine mans equilibrium and Susrhuta, a surgeon of the time,
advised coating honey mixed with butter to an infected ear
lobe after piercing [1].
Hippocrates prescribed honey for burns, boils and
abscesses, while Dioscorides, a physician of the Roman army

Corresponding author. Tel.: +01 56 093 463; fax: +01 56 093 468.
E-mail address: ollivier.laccourreye@egp.aphp.fr
(O. Laccourreye).

in 50 B.C., used honey to treat wounds and inammation

of the throat and tonsils [1]. In the Hippocratic Corpus,
honey is mentioned 542 times (particularly in the treatise
on gynaecology and internal diseases, but also for pleurisy,
diseases of the ileum, as a suppository for haemorrhoids, or
by application to the eye and on wounds) and notes that:
. . .wine and honey are wonderfully adapted to man; both
in health and in disease, they are administered wisely and
justly according to the individual constitution [2]. Finally,
Galen, in De Naturalibus Facultatibus, wrote that honey
is . . . excellent for the elderly, but harmful to the hot
tempered. . . [2].
However, the rst modern scientic article devoted to
the healing properties of honey was only published in
1936 [3] and although the literature devoted to honey has
continued to grow, with more than 920,000 hits on the
Google search engine in 2010 for the combination of
honey and treatment, to our knowledge, no article
has been published on this subject in the French otorhinolaryngology literature. In view of this lack of data, the
authors decided to review the medical literature (PubMed

1879-7296/$ see front matter 2011 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.anorl.2010.12.002

134
Table 1

A. Werner, O. Laccourreye
Honey in religious texts.

Origin

Quotation

Homeric hymn to hermes

. . . yellow honey. . . the gods sweet food. . .

The Bible
Psalm 119: verse 103
Exodus 33: 8

Koran
Sourate 16: verses 6869

How sweet are Your words to my taste, sweeter than honey to my mouth
And I am come down to deliver them out of the hand of the Egyptians, and to
bring them up out of that land unto a good land and a large, unto a land owing
with milk and honey...
And your Lord inspired the bees, saying: Take you habitations in the mountains
and in the trees and in what they erect.
Then, eat of all fruits, and follow the ways of your Lord made easy (for you).
There comes forth from their bellies, a drink of varying colour wherein is healing
for men. Verily, in this is indeed a sign for people who think.

search), and study the composition, mechanism of action,

indications and adverse effects of honey in otorhinolaryngology as well as the future prospects of this gift of the
gods.

Composition of honey
Honey is an acidic product (pH 4) with a variable chemical composition according to the owers from which it is
derived. On average, it is composed of about 80% sugars
(glucose, fructose, sucrose, levulose, maltose, sucrose), 17
to 20% water, and 4% of various other substances (pollen
grains, proteins, enzymes, hydrogen peroxide, amino acids,
organic acids, polyphenols, vitamins (except for vitamin A),
minerals, and more than 100 volatile substances (alcohols,
esters, aromatic substances) [1]. The low water concentration of honey helps to prevent the growth of micro-organisms
(yeasts, fungi, bacteria), but as this product is hygroscopic,
when left in contact with air for several months, its relative
humidity increases to more than 50%, resulting in fermentation [1].
The composition of honey varies according to its source,
the harvest season, the plants from which nectar is
gathered, the modalities of honey collection and storage. As
honey is produced by bees, which collect dust deposited on
plants during pollen gathering, honey is subject to various
potential sources of contamination. The best-known form
of contamination is that due to the pesticides, antibiotics
and acaricides used by beekeepers and farmers. However,
the quantities of these contaminants are very small and
below the limits accepted by the international literature
[4]. Contamination by Caesium (134 and 137) mainly affects
heather honey and is due to atmospheric nuclear tests
and the Chernobyl accident. Finally, honey is not sterile
and can contain bacteria (B. subtilis and C. botulinum). In
2005, Nevas et al. [5], in an analysis of 235 types of honey
taken from hives in Nordic countries (Denmark, Norway,
Sweden), demonstrated the presence of Clostridium
botulinum (serotype A, B, E or F) with an incidence ranging
from 2 to 26% depending on the country. However, honey can
be sterilized by gamma radiation (2.5 cGy) without loosing
its biological properties [6].

Biological effects
The two main biological effects of honey are its antiseptic and healing properties. These properties are classically
attributed to two factors: hydrogen peroxide (H2 O2 ) and
hyperosmolarity [7,8]. The H2 O2 present in honey acts as
a detergent in relation to bacteria present in the wound.
The hyperosmolarity of honey, induced by its very high sugar
content, generates a physical effect: by absorbing water, the
sugars present in honey modify the surface osmotic pressure
in the wound, which mechanically prevents any bacteria
present from adhering and proliferating and also reduces
local inammation by promoting exudation. These biological effects provide ideal conditions for the development of
granulation tissue and healing. In addition to these two factors, recent studies have demonstrated direct antibacterial
effects for two components of honey: methylglycoxal (MGO)
and a protein, bee-defensin 1 [810].
The various published in vitro studies analysing the local
antibacterial activity of honey emphasize that:
this activity concerns a large number of bacteria
(Escherichia coli whether or not beta-lactamase
producing, Enterococcus whether or not vancomycinresistant, Staphylococcus aureus whether or not
methicillin-resistant, Pseudomonas aeruginosa whether
or not ciprooxacin-resistant, Klebsiella pneumoniae, Enterobacter cloacae, Acinetobacter, and
Streptococcus);
the antibacterial activity of honey is 5- to 11-fold higher
than that obtained by application of sugar solutions,
thereby demonstrating that the antibacterial activity is
not simply due to the osmotic effect of its sugars [815].
The many in vitro studies that have compared various
types of honey emphasize variations in their respective hydrogen peroxide, MGO and bee-defensin 1 protein
concentrations, with preferences very clearly inuenced by
the authors nationality. The current standard in terms of
honey is situated in the south hemisphere and Australian and
New Zealand articles all conclude on the superior efcacy of
their honey, Manuka honey derived from an indigenous tree

Honey in otorhinolaryngology: When, why and how?

Table 2

135

The main types of medicinal honey marketed in the world.

Honey name

Company name

Country

Price

Medihoney

MediHoney TM
Comvita Medical
Derma Sciences
Triticum Company
Advancis
Mediprof

Australia
New Zealand
USA
Netherlands
England
Netherlands, Belgium,
England, Greece

10 D

L-Mesitran
Activon
Honeysoft

(Leptospermum scoparium). However, Irish authors conclude on the superiority of Chilean honey derived from the
Ulmo bush (Eucryphia cormen) compared to Manuka honey
[12]. In an Indian study from Madras, the authors concluded
on the superiority of the local honey (Khadikraft) compared to Australian Manuka or British honey [13], while all
Malaysian authors highlight the advantages of Tualang honey
and Dutch authors report that Manuka honey does not contain bee-defensin 1 protein [8,14]. All of these comparisons,
with unanimous conclusions concerning the healing and therapeutic efcacy of these various types of honey, are not
devoid of economic inuences, as several medicinal honeys are now available on the market (Table 2). The current
market of products intended for the treatment of wounds
is considerable. In the USA, in 2010, nancial reviews estimated this market at 14 trillion dollars [16] and the North
American company Derma Sciences Inc. (Princeton, New Jersey), specialized in skin care products, recently acquired a
Manuka honey-based paste approved by the Food and Drug
Administration for the treatment of wounds that it markets
under the brand name of Medihoney .
It should also be emphasized that the presence of
proteins and polyphenols (caffeic acid, chrysin, galangin,
quercetin, apigenin, pinobanksin, pinocembrin, acacetin)
in honey also confers an antioxidant and potentially
antimitotic action. Several studies have demonstrated that
application of honey to the tumour site inhibited tumour
growth in vivo in mice and the growth of various cancer
cell lines in vitro [11,17,18], but no clinical study has yet
been conducted in man to conrm this potential antitumour
action.

Therapeutic properties of honey

Honey is a food and topical application or ingestion of honey
for medicinal purposes treatments must be performed daily.
By topical application (Table 3), the wound is cleaned with
physiological saline and honey is then applied with a compress. Deep wounds can be lled to three quarters, then
covered with a dressing.
Three meta-analyses devoted to evaluation of the
healing properties of honey have been conducted over the
last 10 years. The rst two meta-analyses, published in
2001 and 2008, devoted to the benecial effects of honey
in burns and supercial wounds and acute and chronic
wounds (venous, arterial, diabetic ulcers), concluded that
analysis of the studies published before 2000 and the
19 randomized studies published since 2000 did not formally

13.59 D
8.45 D
On request

and scientically (due to the many, major methodological biases) demonstrate the superiority of honey, compared
to other treatments [7,19]. However, the authors also
reported that the results obtained with honey dressings
in terms of healing, infection control and sterilization are
often superior to those obtained with conventional dressings with or without concomitant antibiotic therapy [7,19].
The most extensive experience of the use of honey in
the eld of wound healing was reported by a French surgeon from Limoges, Prof. Descottes. Based on a cohort
of more than 3000 wounds, 94% of which corresponded to
postoperative wound dehiscences, this author emphasized
the benets of honey (healing after failure of conventional
treatment, two-fold faster healing rate with than tulle gras
dressings, very good cosmetic quality of healing, 98% success rate), and the low cost of the thyme honey used
[20]. Visavidia et al. [21], in Great Britain, emphasized
the value of rst-line honey dressings on rapidly infected
postoperative maxillofacial wounds in their everyday
clinical practice. These published results are in line with our
experience of the regular use of honey in our department
since 1970, under the inuence of Prof. Henri Laccourreye,
by twice daily topical application and regular oral ingestion
several times a day, to treat salivary stula after head and
neck cancer surgery or for any healing problems after head
and neck surgery. According to Ganacias-Acuna [22], honey
can also be combined with the use of negative pressure to
promote wound healing.
In the last meta-analysis published in 2008, devoted
to the role of honey in oncology, Bardy et al. [23] while
concluding on the poor quality of the 40 or so studies analysed due to various methodological problems,
also emphasized that honey is as effective as usual
treatments for radiation mucositis, radiation dermatitis,
chemotherapy-induced hand-foot syndrome and/or postradiotherapy wounds of the skin or oral cavity. The efcacy
of honey in radiation mucositis was recently conrmed by
Rashad et al. [24], who highlighted the efcacy of honey in
prevention of serious mucositis by topical application onto
the oral mucosa followed by ingestion of 20 ml of honey
15 minutes before, 15 minutes after, and 6 hours after each
radiochemotherapy session (6066 Gray; 2 cGy/week; cisplatin 20 mg/m2 once a week).
Recurrent labial herpes lesions also appear to be very
sensitive to topical application of honey. In a randomized
study comparing honey application several times a day (four
times daily for 15 minutes) versus acyclovir (six times daily),
based on analysis of the healing time, pain relief, resolution
of local signs and prevention of acute attacks, Al-Waili [25]

136
Table 3

A. Werner, O. Laccourreye
How to apply honey on a wound.

Clean the wound with physiological saline

Apply honey
Shallow wound: compress soaked in honey (30 ml of honey for a 10 10 cm compress)
Deep wound: directly ll 3/4 of the wound with honey
Cover with an absorbent or occlusive dressing
Change the dressing once or twice a day (rinsing with physiological saline) until the appearance of granulation tissue, then
every 48 hours

concluded on the signicant superiority of honey (P < 0.05)

and attributed the therapeutic effect obtained to the presence of copper, ascorbic acid and hydrogen peroxide in
honey, which inactivate the Herpes simplex virus, and to
local inactivation of prostaglandins.
A last potential indication for honey appears to be cough
and respiratory difculties in children following upper respiratory tract infections. In a double-blind study conducted
in the United States in 2009 on 105 children comparing buckwheat honey versus a classical dextromethorphan-based
antitussive (Drill , Humex ) and no treatment, the authors
concluded on the superiority of honey in the treatment of
nocturnal cough in children over the age of 1 year: less cough
and better sleep for the child and the parents [26].

Limitations and adverse effects of honey

Due to its acidic pH, honey can cause unpleasant or even
painful feelings during application or ingestion that may
limit its use. In a study in rats comparing honey dressings
and conventional dressings for the treatment of auricular
burns, Hashemi et al. [27] reported that the chondritis rate
was higher in the group treated with honey. The proximity of
cartilage may, therefore, constitute a limiting factor to the
healing efcacy of honey. Similarly, according to Descottes
[20], a history of local radiotherapy limits the healing
properties of honey on skin wounds. Allergy to honey or its
ingredients and pollutants is extremely rare, but possible
[1].
The main issue concerning the adverse effects of honey
concerns the risk of botulism. Due to the presence of
Clostridium botulinum spores (but not botulinum toxin)
in honey derived from many hives [5] and inactivation of
these spores by low-dose gamma radiation (2 cGy) [6], it
is frequently recommended in the medical literature that
only irradiated honey should be ingested and/or applied to
wounds. However, there are no published cases of botulism
in adults following the ingestion or topical application of
honey, despite the fact that the very great majority of
studies on honey were conducted in developing or lowincome countries, in which gamma sterilization of honey is
not performed. Similarly, in France, no cases of botulism
were reported in the cohort published by Descottes [20] (in
which honey does not appear to have been sterilized) or
in our own experience (in which a commercially available
food honey has been used since 1970 to treat salivary stula and/or wounds after neck surgery). Finally, the cases
of botulism reported in adults in France are not related to
ingestion of honey despite the fact that this product is extensively used by the population [28]. However, several cases

of botulism related to honey have been reported in infants

under the age of 1 year in the United States and France,
where the incidence of this disease has been increasing
since 2000 [26,28,29]. In these cases, honey is ingested as
treatment or as a food supplement. Clostridium botulinum
then proliferates in an immature gastro-intestinal system
and produces botulinum toxin which subsequently induces
botulism. Honey, that has not been sterilized by gamma radiation, should therefore not be used as a sweetener, food
substrate and/or in the context of medicinal ingestion in
infants under the age of 1 year [26,28,29].
In the light of the published scientic data and the experience acquired over the last 30 years in Limoges, in Prof.
Descottes Department of Surgery [20], and in Paris, in
the Department of Otorhinolaryngology and Head and Neck
Surgery at Lannec hospital and then, at the Georges Pompidou European hospital (no cases of botulism reported after
application of honey to neck wounds, pharyngostome and/or
radiation mucositis), the food honey available in France
can, therefore, be used in patients over the age of 1 year
in otorhinolaryngology and head and neck surgery with no
medicolegal risks at the present time.

Conclusion
In this age of budget restrictions and optimization of medical
resources, the research and development of effective and
inexpensive treatments constitute a major concern for all
clinicians. In this context, application of honey to inamed
mucosa and head and neck skin or mucosal wounds provides
a real therapeutic benet. The local action of honey on
multiresistant bacteria also participates in more effective
antibiotic practices. The antitussive action of honey also
appears to be useful in infants over the age of 1 year. The
other properties (antioxidant and antimitotic) of systemic
administration of honey need to be formally demonstrated
by in vivo studies, although many articles based on animal experimentation and cell culture are in favour of these
effects. None of the thousands of varieties of honey available throughout the world appears to be truly superior.
Various countries, such as Australia and the United States
have already developed the medicoeconomic use of this
product. When will a French medicinal honey be available?

Conicts of interest statement

None.

Honey in otorhinolaryngology: When, why and how?

Acknowledgements
The authors would like to thank Progrs 2000 for technical
and nancial support for this study.

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