Chest Wall Deformities (Pectus Excavatum or Carinatum)

Pectus excavatum, also known as sunken, funnel or caved-in chest, is the most common congenital disorder (present at birth) of the front (anterior) chest wall. It is the result of abnormal growth of the cartilages between the ribs and the breastbone (sternum). The abnormal growth causes the breastbone to move inward or rotate to one side. Pectus excavatum usually involves the middle lower portion of the breastbone and may worsen with age. The abnormality may be unequal, or asymmetrical, between the right and left sides.  

Pectus carinatum, or pigeon chest, is much less common than pectus excavatum but arises from the same abnormality of the breastbone and rib cartilages. In this case the breastbone protrudes out, usually asymmetrically.

Causes

Although the exact cause of pectus is unknown, almost half of people with this condition have a family history of it. Pectus excavatum affects three times as many males than females. Overall, it affects about in one in 1,000 people.

Symptoms

  • Difficulty exercising 
  • Shortness of breath
  • Chest and back pain 
  • Psychosocial affects: Many teenagers feel self-conscious about their body image, which can lead to social isolation.

Diagnosing Pectus Deformities

  • Chest X-ray: visualizes the dip in the breastbone and typically shows the heart being displaced into the left side of the chest
  • CT scan: determines the severity of the condition and whether the heart or lungs are compressed
  • Echocardiogram: sonogram of the heart (performed using sound waves) that evaluates displacement of the heart
  • Pulmonary function testing: evaluates lung restriction
  • Exercise test: monitors how well your heart and lungs function during exercise

Treatments

Treatment for pectus excavatum can involve exercises or surgery. Surgical repair has been shown to improve exercise capability and psychosocial state. Individuals who have a moderate to severe deformity may be a good fit for surgery. Those who have little to no symptoms may seek treatment to improve the appearance of their chest.


Testing is done before surgery to determine the severity of the pectus deformity. These tests typically include a CT scan of the chest, an ultrasound of the heart (echocardiogram) and breathing tests (pulmonary function studies).


Thoracoscopic-assisted Nuss procedure is a minimal access technique that uses small incisions and a small camera placed in the right chest (and sometimes in the left chest, too). One to three bars are placed under the breastbone to gradually remold the breastbone to a flatter shape. The bars stay in place for about two to four years, depending upon your age. This operation relies on skeleton remodeling, thus the long duration of bar requirement in adults.


Some people are candidates for a modified Ravitch procedure, which involves a larger incision, surgical removal of the abnormal cartilages and breastbone support with a much smaller bar, allowing the ribs to regrow in the new, more normal position. This operation is recommended for those with asymmetry or who want a shorter duration of bar requirement (typically one to two years).


Pain management is central to these operations. Individuals usually see a dramatic difference in their exercise capability, after recovering from surgery.