Quinsy or peritonsillar abscess is a complication of untreated tonsillitis.  It may also be caused by an inadequately treated tonsillitis caused by multidrug resistant organisms (MDROs).  The most common are Strep, Staph and Hemophilus.  There are becoming more and more cases of multi-drug resistant community-acquired Strep pneumonia (see sample lab culture) and MRSA is commonplace in the United States.   Some of these community acquired MDRO are resistant to almost all antibiotics, because of this, quinsy is becoming more common. 

A peritonsillar abscess refers to a severe infection where pus forms between the tonsil and tonsillar capsule/superior pharyngeal constrictor.  The abscess is behind not in the tonsil.  Patients with massively enlarged tonsils that are covered with pus and have little peritonsillar swelling, usually do not have a peritonsillar abscess. 

Diagnosis of a peritonsillar abscess is by physical exam.  The patient has a characteristic hot potato voice, often having difficulty swallowing.  With severe cases, trismus (difficulty moving the mouth) from spasm of the jaw muscles may occur.  The appearance of the pharynx is shown in the above left photograph and photograph on the right.  The anterior tonsillar pillar is distended and widened (see long blue arrows in above left photograph).  The uvula is deviated to the opposite side.  The tonsil, itself, is often not as prominent as the swelling of the tonsillar pillar.   Confirmation of a suspected peritonsillar abscess can be done by needle aspiration or CT scan.

Treatment of a peritonsillar abscess is a medical emergency.  Many references can be found which attributes George Washington's death to Quinsy.  However, a careful analysis of his case makes the most likely cause of death epiglotitis.  See Reference   Infection from a peritonsillar abscess can spread to the parapharyngeal space and from there into the mediastinum -- See Reference.      

The initial step in treatment may involve incision and drainage and broad spectrum antibiotics-- See Reference.  Incision and drainage can be performed under local anesthesia on an outpatient basis.  If necessary, the procedure can be repeated in two to three days.  In patients who are over 40 years old that do not have a history of recurrent tonsillitis, no further treatment may be necessary-- See Reference.  Authors have also cited a low recurrence rate (16%) in children and argue against routine tonsillectomy-- See Reference.   In other patients, a delayed tonsillectomy in four to six weeks may be performed.  Timing of this procedure is designed to allow the infection and inflammation to subside but is done before scaring sets in.   However, some authors advocate immediate tonsillectomy citing cost savings and safety--See Reference, See Reference, See Reference; as other authors advocate unilateral tonsillectomy citing increased bleeding due to inflammation in the opposite side--See Reference.  On the other end of the spectrum are authors who advocate only aspiration without incision and drainage or tonsillectomy--See Reference,  See Reference,  See Reference.

 Incision and Drainage Video to treat a Peritonsillar Abscess: