What are the challenges in choosing pharmacotherapy for rhinosinusitis?

Introduction: Rhinosinusitis is an extremely prevalent condition with significant health-care expenditure and socio-economic burden. Although symptomatically patients with acute and chronic rhinosinusitis present similarly, the underlying pathogenesis of these conditions is different.Areas covered: This perspective discusses the various treatment options for both acute and chronic rhinosinusitis and examines some of the challenges in choosing appropriate pharmacotherapy. It examines the evidence supporting the commonly used agents including saline irrigations, topical and oral corticosteroids and antibiotics and makes recommendations based on the highest level of evidence available. Furthermore, the role or precision medicine and emerging therapies such as biologics are discussed.Expert opinion: Despite being commonly prescribed, the evidence supporting the routine use of oral antibiotics for CRS and the majority of ARS is lacking. The authors suggest judicious use of these medications after clear consideration of the indications. Topical intranasal corticosteroids and saline irrigations remain a safe and effective treatment for rhinosinusitis and should be considered as first-line therapy. In patients who fail to respond to appropriate treatment, therapy should be escalated after consultation and review by a specialist.