What causes a sore tongue and throat?

Sore Tongue and Throat: Causes and Evaluation

Sore tongue and throat are most commonly caused by viral infections, but require systematic evaluation to identify bacterial infections requiring treatment (particularly Group A Streptococcus), serious life-threatening complications, and specific tongue pathologies including burning mouth syndrome and nutritional deficiencies. 1, 2, 3

Infectious Causes of Sore Throat

Viral Etiologies (Most Common)

• Respiratory viruses account for the vast majority of pharyngitis cases, including adenovirus, influenza, parainfluenza, rhinovirus, and respiratory syncytial virus 3
• Epstein-Barr virus (EBV), Cytomegalovirus (CMV), Coxsackievirus, and Herpes simplex virus are other important viral agents 3, 4
• Viral pharyngitis is suggested by conjunctivitis, coryza, cough, diarrhea, and leukocyte count <10,000/mm³ 3
• Adenovirus can present with prominent exudative pharyngitis that mimics streptococcal infection 3

Bacterial Causes Requiring Treatment

• Group A Streptococcus is the primary bacterial pathogen requiring antibiotic therapy to prevent rheumatic fever 5, 3, 4
• Use the modified Centor score to assess streptococcal risk: fever, tonsillar exudate, swollen tender anterior cervical nodes, absence of cough, plus age adjustment 1
• A score of ≥4 indicates 51-53% risk of Group A Streptococcus; score ≤0 indicates 1-2.5% risk 1
• Group C and G streptococci can cause severe or recurrent pharyngitis but have insufficient evidence for other adverse outcomes 1
• Fusobacterium necrophorum is an emerging pathogen in adolescents and young adults that can progress to life-threatening Lemierre syndrome and requires anaerobic antibiotic coverage 5
• Mycoplasma pneumoniae and Chlamydia pneumoniae are associated with non-streptococcal pharyngitis, particularly in atypical presentations 1, 4
• Neisseria gonorrhoeae causes pharyngitis in sexually active individuals 5, 4

Life-Threatening Complications Requiring Urgent Evaluation

In patients with severe refractory sore throat, immediately evaluate for peritonsillar abscess, retropharyngeal abscess, epiglottitis, or Lemierre syndrome rather than continuing empiric antibiotics 2

Red Flag Signs by Condition

• Peritonsillar abscess: unilateral tonsillar swelling, uvular deviation, trismus, "hot potato voice," difficulty swallowing 2
• Retropharyngeal abscess: neck stiffness, neck tenderness or swelling, drooling, difficulty swallowing 2
• Epiglottitis: drooling, stridor, sitting forward position, respiratory distress (airway management is paramount) 2, 4
• Lemierre syndrome: severe pharyngitis in adolescents/young adults progressing to septic thrombophlebitis from Fusobacterium necrophorum 2, 5

Tongue-Specific Pathology

Burning Mouth Syndrome

• Burning mouth syndrome is a chronic neuropathic condition characterized by burning of the tongue and oral mucosa with normal-appearing tissue, seen predominantly in peri- and post-menopausal women 1
• The tongue tip, lips, palate, and buccal mucosa are most commonly affected bilaterally with continuous burning, stinging, or itchy sensations 1
• Secondary causes must be excluded: oral candidiasis, mucosal lesions, hematological disorders (iron, B12, folate deficiency), autoimmune disorders, and medication side effects 1, 6
• Management includes reassurance that it will not worsen, cognitive behavioral therapy, and possibly neuropathic pain medications 1

Common Benign Tongue Conditions

• Geographic tongue, fissured tongue, and hairy tongue are the most common tongue problems and do not require treatment 6
• Median rhomboid glossitis is usually associated with candidal infection and responds to topical antifungals 6
• Atrophic glossitis is linked to nutritional deficiency of iron, folic acid, vitamin B12, riboflavin, or niacin and resolves with correction 6
• Oral hairy leukoplakia is caused by Epstein-Barr virus, can indicate immunodeficiency, and is treated with oral antivirals 6

Infectious Tongue Lesions

• Candidal infection in the appropriate clinical context should suggest HIV infection 4
• Herpes simplex and varicella-zoster virus can cause vesicular lesions on the tongue 7
• Coxsackie A virus causes herpangina with characteristic vesicles 4

Diagnostic Approach

Initial Clinical Assessment

• Look for obvious viral features: conjunctivitis, coryza, cough, diarrhea to avoid unnecessary testing 3, 8
• Apply modified Centor criteria for patients without clear viral syndrome: fever, tonsillar exudate, tender anterior cervical adenopathy, absence of cough, age-adjusted scoring 1
• Examine for scarlatiniform rash (suggests Streptococcus pyogenes or Corynebacterium haemolyticum), membrane (diphtheria), or cherry-red epiglottis (Haemophilus influenzae type b) 4

Laboratory Testing

• Rapid antigen detection test has high specificity (≥95%) but lower sensitivity for Group A Streptococcus 1
• Throat culture remains gold standard but requires 18-24 hours for results 1
• Consider testing for gonorrhea in sexually active patients with pharyngitis 5

When to Investigate Further

• Severe refractory symptoms warrant urgent imaging and specialist evaluation for abscess, epiglottitis, or Lemierre syndrome 2
• Tongue lesions of unclear etiology require biopsy to differentiate benign lesions from premalignant leukoplakia or squamous cell carcinoma 6
• Persistent burning tongue symptoms require evaluation for nutritional deficiencies, candidiasis, and systemic conditions before diagnosing burning mouth syndrome 1, 6

Management Pitfalls

• Do not continue empiric antibiotics in severe refractory pharyngitis without identifying the underlying cause, as antibiotics provide minimal benefit for viral pharyngitis and may delay diagnosis of life-threatening complications 2
• Chlamydia trachomatis detected in pharyngeal specimens represents colonization from oral-genital contact, not the cause of pharyngitis—look for another etiology 5
• Continue ibuprofen or acetaminophen for pain control while investigating severe pharyngitis 2