Management of Chronic Sinusitis with Concurrent Asthma
Continue the steroid inhaler and add intranasal fluticasone propionate (not oral antihistamine/montelukast combinations) as the primary treatment, with consideration of adding montelukast as adjunctive therapy if symptoms remain inadequately controlled after optimizing intranasal corticosteroids. This approach addresses both the chronic rhinosinusitis and asthma while avoiding premature discontinuation of effective therapy.
Why Continue the Steroid Inhaler
Stopping inhaled corticosteroids in a patient with asthma is contraindicated, as this patient has demonstrated both asthma requiring bronchodilator therapy and chronic sinusitis—conditions that are strongly linked and require concurrent treatment 1.
The relationship between sinusitis and asthma is bidirectional: 84-100% of patients with severe asthma have abnormal sinus CT findings, and treating sinusitis improves asthma control while decreasing the need for asthma medications 1.
Medical treatment of sinusitis in asthmatic patients results in significant improvement in asthma symptoms, pulmonary function, and decreased systemic corticosteroid requirements 1.
Primary Treatment Strategy: Intranasal Corticosteroids
Intranasal corticosteroids (such as fluticasone propionate 200 mcg/day per nostril) are the most effective single agent for chronic rhinosinusitis, particularly in patients with eosinophilic inflammation commonly seen with concurrent asthma 2, 3.
Fluticasone propionate aqueous nasal spray at standard or even double the usual dose (800 mcg/day total) is effective for chronic sinusitis with eosinophils, improving nasal discharge, obstruction, and CT findings with minimal systemic absorption (<1%) 4.
The temporary relief experienced with the "steroid inhaler" (likely intranasal corticosteroid) confirms the inflammatory nature of this sinusitis and indicates that continuing and optimizing intranasal corticosteroid therapy is essential 5, 4.
Role of Montelukast: Adjunctive, Not Primary
Montelukast should NOT replace intranasal corticosteroids, as it is significantly less effective than intranasal corticosteroids for controlling nasal symptoms 2, 3, 6.
In a direct comparison study, fluticasone propionate nasal spray was superior to montelukast for all nasal symptoms (congestion, rhinorrhea, sneezing, itching) in patients with both allergic rhinitis and asthma 6.
However, adding montelukast to intranasal fluticasone may provide additional benefit in patients with chronic rhinosinusitis and asthma who remain symptomatic on intranasal corticosteroids alone 5.
Combined treatment with intranasal fluticasone propionate (200 mcg/day) plus montelukast (10 mg/day) for at least 1 year significantly reduced nasal polyp size, CT shadow scores, and peripheral eosinophil counts in patients with chronic rhinosinusitis and adult-onset asthma 5.
Why Oral Antihistamines Are Not the Answer
Oral antihistamines alone are insufficient for chronic sinusitis, particularly the eosinophilic type associated with asthma 2, 3.
While antihistamines may help if there is an allergic component, they do not address the underlying inflammatory process in chronic rhinosinusitis as effectively as intranasal corticosteroids 2.
The combination of oral antihistamine plus leukotriene antagonist is reserved for patients who cannot tolerate or are non-compliant with intranasal corticosteroids—not as first-line therapy 2.
Role of Antibiotics
Antibiotics are indicated if there is evidence of acute bacterial superinfection (purulent discharge, fever, facial pain, air-fluid levels on imaging), but chronic sinusitis lasting 6 months is typically not primarily infectious 1, 7.
In chronic rhinosinusitis associated with asthma, the pathophysiology is predominantly inflammatory (eosinophilic) rather than infectious, making anti-inflammatory therapy more important than antibiotics 1, 5.
If imaging shows air-fluid levels suggesting acute bacterial sinusitis, then amoxicillin or amoxicillin-clavulanate would be appropriate alongside continued anti-inflammatory therapy 7.
Practical Treatment Algorithm
Continue salbutamol as needed for asthma symptom relief 1.
Optimize intranasal fluticasone propionate (200-400 mcg per nostril daily), ensuring proper administration technique (spray directed away from nasal septum) 2, 4.
If inadequate response after 2-4 weeks, add montelukast 10 mg daily as adjunctive therapy 5.
Consider adding oral antihistamine (second-generation like levocetirizine) only if there is clear allergic component with sneezing, itching, and watery rhinorrhea 2.
If symptoms persist despite 6-12 weeks of combined medical therapy, obtain sinus CT imaging to assess for anatomic abnormalities, extensive polyposis, or complications requiring ENT referral 1.
Critical Pitfalls to Avoid
Never discontinue inhaled corticosteroids in an asthmatic patient without ensuring adequate alternative controller therapy—this patient needs both upper and lower airway anti-inflammatory treatment 1.
Do not use montelukast as monotherapy for chronic rhinosinusitis when intranasal corticosteroids are available and tolerated 2, 3, 6.
Recognize that "temporary relief" followed by recurrence indicates inadequate treatment duration or dosing, not treatment failure—chronic rhinosinusitis requires prolonged therapy (months, not weeks) 5, 4.
Answer to the Multiple Choice Question
Option C is closest to correct: Continue the steroid (specifically intranasal fluticasone propionate, not just any steroid inhaler) and consider adding montelukast if needed. However, the phrasing "montelukast inhaler" is incorrect—montelukast is an oral tablet, not an inhaler 5. The optimal approach is intranasal fluticasone propionate (continued/optimized) with possible addition of oral montelukast 10 mg daily if symptoms remain inadequately controlled after 2-4 weeks 5, 6.