Pectus excavatum

Definition

Pectus excavatum is a condition in which a person's breastbone is sunken into his or her chest. The chest bows inward instead of outward. In severe cases, pectus excavatum can look as if the center of the chest has been scooped out, leaving a deep dent.

While the sunken breastbone is often noticeable shortly after birth, the severity of pectus excavatum typically worsens during the adolescent growth spurt.

Also called funnel chest, pectus excavatum is more common in boys than in girls. Severe cases of pectus excavatum can eventually interfere with the function of the heart and lungs. But even mild cases of pectus excavatum can make children feel self-conscious about their appearance. Surgery can correct the deformity.

Pectus excavatum

Pectus excavatum

Pectus excavatum is a condition in which a person's breastbone is sunken into his or her chest. The chest bows inward instead of outward. Severe cases of pectus excavatum can eventually interfere ...

Symptoms

For many people with pectus excavatum, their only sign or symptom is a slight indentation in their chests. In some people, the depth of the indentation worsens in early adolescence and can continue to worsen into adulthood.

In severe cases of pectus excavatum, the breastbone may compress the lungs and heart. Signs and symptoms may include:

• Decreased exercise tolerance
• Rapid heartbeat or heart palpitations
• Recurrent respiratory infections
• Wheezing or coughing
• Chest pain
• Heart murmur
• Fatigue

Causes

While the exact cause of pectus excavatum is unknown, it may be an inherited condition because it sometimes runs in families.

Pectus excavatum can occur in conjunction with other medical conditions, such as:

• Marfan syndrome. This hereditary condition affects the connective tissue, often resulting in limbs and fingers that are especially long and thin.
• Scoliosis. An abnormal curvature of the spine, scoliosis usually occurs in pre-adolescent girls.
• Mitral valve prolapse. The mitral valve separates the two chambers of the left side of the heart. Defects in the mitral valve may reduce the heart's efficiency in pumping blood.

Risk factors

Pectus excavatum is more common in boys than in girls.

Complications

Severe cases of pectus excavatum can compress the lungs and push the heart over to one side. Even mild cases of pectus excavatum can result in self-image problems.

Heart and lung problems
If the depth of the breastbone indentation is severe, it may reduce the amount of room the lungs have to expand. This compression can also squeeze the heart, pushing it into the left side of the chest and reducing its ability to pump efficiently.

Self-image problems
Children who have pectus excavatum also tend to have a hunched-forward posture, with flared ribs and shoulder blades. Many are so self-conscious about their appearance that they avoid activities, such as swimming, where the indentation in their chests is more difficult to camouflage with clothing.

Pectus excavatum

Pectus excavatum

Pectus excavatum is a condition in which a person's breastbone is sunken into his or her chest. The chest bows inward instead of outward. Severe cases of pectus excavatum can eventually interfere ...

Preparing for your appointment

If you or your child has pectus excavatum, you might first discuss the matter with your family doctor. He or she may refer you to a doctor who specializes in orthopedic surgery.

What you can do
You may want to write a list that includes:

• Detailed descriptions of the signs and symptoms
• Information about past medical problems
• Information about medical problems common in your family
• All the medications and dietary supplements you or your child takes
• Questions you want to ask the doctor, including what treatments are available

What to expect from your doctor
Your doctor may ask some of the following questions:

• When did these signs and symptoms begin?
• Have they worsened recently?
• Has anyone else in your family had a similar problem?

Tests and diagnosis

Pectus excavatum can usually be diagnosed simply by examining the chest. But your doctor may suggest several different types of tests to check for associated problems with the heart and lungs. These tests may include:

• Chest X-ray. This test can visualize the dip in the breastbone and often shows the heart being displaced into the left side of the chest. X-rays are painless and take only a few minutes to complete.
• Computerized tomography (CT). A CT scan may be used to help determine the severity of the pectus excavatum and whether the heart or lungs are being compressed. CT scans take many X-rays from a variety of angles to produce cross-sectional images of the body's internal structure.
• Electrocardiogram. An electrocardiogram can show whether the heart's rhythm is normal or irregular, and if the electrical signals that control the heartbeat are timed properly. This test is painless and involves the placement of more than a dozen electrical leads, which are attached to the body with a sticky adhesive.
• Echocardiogram. An echocardiogram is a sonogram of the heart. It can show real-time images of how well the heart and its valves are working. The images are produced by transmitting sound waves via a wand pressed against the chest.
• Lung function tests. These types of tests measure the amount of air your lungs can hold and how quickly you can empty your lungs. In some cases, these tests are performed while the person is exercising on a treadmill.
• Exercise test. This test monitors how well your heart and lungs function while you exercise, usually on a treadmill.

Treatments and drugs

Pectus excavatum can be surgically repaired, but surgery is usually reserved for people who have moderate to severe signs and symptoms. People who have mild signs and symptoms may be helped by physical therapy. Certain exercises can improve posture and increase the degree to which the chest can expand.

If you have mild pectus excavatum, your doctor may want to re-evaluate you every six to 24 months, to make sure your symptoms haven't worsened.

Types of surgery
If you have moderate to severe pectus excavatum, your doctor may suggest surgery. The two most common types of surgeries used to correct pectus excavatum differ by the size of the incisions used:

• Larger incision. The larger, center-of-the-chest incision used in the Ravitch technique allows the surgeon to view the breastbone directly. The abnormal cartilage attaching the ribs to the lower breastbone is removed and the breastbone is fixed into a more normal position with surgical hardware, such as a metal strut or mesh supports. These supports are removed in nine to 12 months.
• Smaller incisions. In the minimally invasive Nuss procedure, small incisions are placed on each side of the chest, under each arm. Long-handled tools and a narrow fiber-optic camera are inserted through the incisions. A curved metal bar is threaded under the depressed breastbone, to raise it into a more normal position. In some cases, more than one bar is used. The bars are removed after two years.

Comparable risks and outcomes
Both the Ravitch and Nuss procedures have been revised and improved over the years. While the Ravitch technique takes longer to complete, the Nuss procedure typically results in a longer hospital stay. Success rates are higher at hospitals that perform more of these types of surgeries.

Most people who undergo surgery to correct pectus excavatum are happy with the change in how their chests look, no matter which procedure is used. Either procedure also improves heart function. Best results are achieved when the surgery is performed after the age of 8 and before the end of adolescence, but adults also have benefitted from these types of surgeries.

Coping and support

Most adolescents just want to fit in and look like their peers. This can be exceptionally difficult for youngsters who have pectus excavatum. In some cases, counseling may be needed to help master coping skills. Online support groups and forums also are available, where you can talk with people who are facing the same types of problems.