Pectus excavatum (sunken chest/funnel chest)

What is pectus excavatum (sunken chest/funnel chest)?

Pectus excavatum is believed to result from an abnormal growth of rib cartilage that causes the sternum (breastbone) to be pulled inward, resulting in a depression in the chest. For this reason, pectus excavatum is also known as sunken chest or funnel chest.

Risk factors

The condition occurs in at least 1 out of every 1,000 children and is more common in males.

What are the signs and symptoms of pectus excavatum (sunken chest/funnel chest)?

Pectus excavatum can range from mild to severe, and your child may or may not have symptoms related to the heart or lungs.

Symptoms include:

• A depression of the sternal bone

• Intermittent shortness of breath

• Decreased endurance with exercise

• Chest pain related to abnormal bone and cartilage growth

• A worsening of symptoms as the child grows

Pectus excavatum often worsens with age and during growth spurts that occur in late childhood and adolescence. Some patients are very self-conscious because of the pectus excavatum deformity.

Correction of the deformity may play a significant role in improving the self-esteem and exercise intolerance of some patients.

How is pectus excavatum (sunken chest/funnel chest) diagnosed?

To diagnose pectus excavatum, your child’s provider will do a detailed physical examination. After diagnosis, additional testing may be ordered to identify the extent of the chest wall deformity and any body system dysfunction, which may include the following tests:

• Computed Tomography (CT) Scan uses X-rays to produce multiple images of the inside of the body. These three-dimensional pictures of the chest can show how severe the condition may be and if the heart and lungs are affected. The primary indication for the chest CT scan is to calculate a "Haller Index" which measures the severity of the chest wall depression.

• Electrocardiogram (EKG) and echocardiography (ECHO) help the doctor see if your child’s heart is under any stress related to the location of the sternum.

• Pulmonary (lung) function test (PFT) helps the doctor see if your child’s lungs are restricted due to the depression of the sternum.

• Chest X-ray test can be helpful to exclude any other problems within the chest itself.

What are the causes of pectus excavatum (sunken chest/funnel chest)?

The exact cause of pectus excavatum is unknown, but we do know it tends to occur in families, suggesting genetics may play a role. It may also be associated with Marfan syndrome, homocystinuria and Ehlers-Danlos syndrome.

How is pectus excavatum (sunken chest/funnel chest) treated?

Treatment is dependent on severity as well as symptoms and can range from simple observation to surgical repair.

• Mild pectus excavatum can include exercises aimed at improving posture and upper body strength.

• Moderate to severe pectus excavatum, reconstruction may be recommended. Most often, this surgery is recommended after age 13 but may be performed sooner or later depending on the individual patient needs.

Surgery

The Nuss procedure

This minimally invasive procedure usually requires a total of three small incisions located on your child’s chest. A curved metal bar shaped to your child’s chest is inserted under the ribs and is secured under the sternum to lift the chest. Multiple bars may be needed.

The bar is placed under direct observation using a small camera so the surgeon can safely pass the bar(s) behind the sternum. The bar is left in place for two to three years to allow the chest wall to remold. The bar is then removed during outpatient surgery.

The Ravitch procedure

This surgical procedure is for children and adolescents and is performed when bracing has not been successful or not possible due to the chest wall deformity. The procedure generally requires an incision across the chest.

The surgeon will remove the abnormal rib cartilage between the boney ribs and the breastbone which allow the breastbone to be pushed down and take its normal shape. An absorbable strut will be placed in your child's chest to keep the breastbone in place until the cartilage can regrow.

Post-op pain management

As with any operation, post-operative pain is a common concern. Our team has developed a protocol with the assistance of the pain team and anesthesiology to minimize the length of time requiring pain medication. Extensive education will be provided in the pre-operative visits by the clinical coordinator for the Pectus clinic.

During the procedure, the surgeon will use cryotherapy to provide pain relief in the areas of the chest wall affected by the surgeon. Most patients will require pain medication at time of discharge but are usually tapered off by the two-week post-operative evaluation.