Recently, I saw a patient who I had not seen for several months. The patient had refractory chronic sinusitis with recurrent bronchitis for several years. She had been identified as having an underlying immunoglobulin deficiency and was receiving IVIG therapy on a regular basis. Despite having acceptable IgG and subclass levels, she continued to be symptomatic, requiring numerous courses of antibiotics.
The patient did have a diagnosis of Gastroesophageal Reflux Disease (GERD) and was on maximal medical therapy for GERD, but it was obvious that her reflux was still a major risk factor for her recurrent chronic sinusitis and bronchitis, despite adhering to lifestyle changes for GERD. The patient had also been diagnosed with obstructive sleep apnea (OSA), but she was not compliant with her CPAP.
When I asked her why it had been several months since I had seen her last, she smiled and said that she finally found a CPAP mask that worked for her and that she was now compliant with her CPAP.
This is a classic case of CORE syndrome: Chronic cough/asthma, OSA, Rhinosinusitis and Esophageal reflux disease. The syndrome is not well known in the medical literature but is pretty obvious when you consider how all of these conditions are interwoven.
For many patients who have obstructive sleep apnea associated with GERD, medical management alone for the reflux will not prevent gastric contents from reaching the lungs or the sinuses. In one study, it is believed that approximately 60% of patients with OSA also experienced GERD. The most likely reason for this is due to the changes in pressure that occur in the chest cavity during the apneic event that allow gastric contents to be brought up back through the esophagus from the stomach and make their way into the sinus cavities and lungs. It should also be realized that correcting patients’ obstructive sleep apnea with CPAP can result in reducing the symptoms of GERD.
The above patient demonstrated a classic presentation of CORE syndrome. For those who have GERD and are not responding to medical management plus lifestyle changes—and who are not candidates for surgical intervention—it may be necessary to consider a diagnosis of OSA.