What throat problems can cause a burning sensation in the tongue?

Burning Sensation in the Tongue: Throat and Related Problems

A burning sensation in the tongue can result from gastroesophageal reflux disease (GERD) with laryngopharyngeal reflux, burning mouth syndrome, or less commonly from oral candidiasis, nutritional deficiencies, or neuropathic conditions. 1

Primary Differential Diagnosis

Laryngopharyngeal Reflux (LPR)

• LPR represents retrograde movement of gastric contents into the laryngopharynx, causing burning tongue sensations even without typical heartburn symptoms. 2, 3
• Only 35% of LPR patients report heartburn, making this a "silent" reflux condition in most cases. 3
• Associated symptoms include chronic throat clearing, globus sensation (lump in throat), hoarseness, chronic cough, and excess mucus production. 4, 3, 5
• The laryngeal mucosa requires less acid exposure than the esophagus to sustain injury, so intermittent small amounts of gastric content can cause symptoms. 4

Diagnosis of LPR:

• Laryngoscopy showing laryngeal edema and erythema supports the diagnosis. 4
• Intraluminal esophageal pH monitoring is the test of choice when diagnosis is uncertain. 6
• Clinical diagnosis based on symptoms and laryngeal findings is acceptable for initiating empiric therapy. 4

Treatment approach for LPR:

• Twice-daily proton pump inhibitors (PPIs) for 2-4 months represent first-line therapy. 4, 3, 6
• Combine with dietary modifications (avoid acidic foods, caffeine, late meals) and behavioral changes (elevate head of bed, avoid lying down after eating). 3, 5
• If unresponsive to PPI therapy after 4 months, consider alternative diagnoses or surgical fundoplication. 4, 6

Burning Mouth Syndrome (BMS)

• Primary BMS is a disorder of peripheral nerve fibers with central nervous system changes, affecting predominantly peri- and post-menopausal women. 7, 1
• Presents as continuous burning, stinging, or itchy sensation most commonly on the tongue tip bilaterally, with normal-appearing oral mucosa on examination. 7, 1
• Associated with dry mouth, abnormal taste, depression, and poor quality of life. 7, 1
• Prognosis is poor with only small numbers achieving full resolution, though symptoms typically do not worsen. 7

Secondary causes requiring exclusion before diagnosing primary BMS:

• Oral candidiasis (diagnosed by scraping and KOH preparation). 1
• Nutritional deficiencies: vitamin B12, iron deficiency anemia (check CBC, B12 levels, ferritin, serum iron, TIBC). 1
• Autoimmune diseases: Sjögren's syndrome, sicca syndrome. 1
• Thyroid disorders, particularly hyperthyroidism. 1
• Medication side effects. 1
• Mucosal lesions from trauma, thermal burns, or chemical injury. 1

Management of BMS:

• Reassurance and education that symptoms will not worsen is crucial. 7
• Cognitive behavioral therapy (CBT) is recommended. 7
• Neuropathic pain medications (gabapentin, tricyclic antidepressants) may be considered, though evidence is limited. 7
• Topical measures and saliva substitutes for associated dry mouth. 7

Critical Diagnostic Algorithm

Step 1: Exclude secondary causes

• Order CBC with differential, vitamin B12, iron studies (ferritin, serum iron, TIBC). 1
• Perform oral examination for candidiasis, mucosal lesions, or traumatic factors. 1
• Review medication list for potential causative agents. 1

Step 2: Assess for LPR symptoms

• Ask specifically about throat clearing, globus sensation, hoarseness, chronic cough, and excess mucus. 3, 5
• Note that absence of heartburn does NOT exclude LPR. 3
• Consider laryngoscopy if diagnosis uncertain or symptoms persist. 4

Step 3: Initiate empiric therapy

• If LPR symptoms present: Start twice-daily PPI for 2-4 months with dietary/behavioral modifications. 4, 3, 6
• If no LPR symptoms and secondary causes excluded: Diagnose primary BMS and initiate reassurance, CBT, and consider neuropathic pain medications. 7, 1

Important Caveats

• Do not routinely prescribe antibiotics for burning tongue, as this is not a bacterial infection. 7
• Empiric PPI therapy without laryngoscopy is acceptable for LPR but should be limited to 2-4 months; if ineffective, reconsider the diagnosis. 2, 4
• Distinguish globus sensation (improves with eating) from dysphagia (worsens with eating), as they require different management approaches. 8
• Immunotherapy-related oral dysesthesia should be considered in patients receiving checkpoint inhibitors, managed with gabapentin or high-potency topical steroids. 7
• Long-term PPI use carries risks including impaired cognition, bacterial gastroenteritis, pneumonia, hip fractures, vitamin B12 deficiency, and chronic kidney disease; use only when indicated. 7