Pectus excavatum

Overview

Pectus excavatum is a condition in which the person's breastbone is sunken into the chest. 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.

Symptoms

For many people with pectus excavatum, the 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
• Dizziness

Causes

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

Risk factors

Pectus excavatum is more common in boys than in girls. It also occurs more often in people who also have:

• Marfan syndrome
• Ehlers-Danlos syndrome
• Osteogenesis imperfecta
• Noonan syndrome
• Turner syndrome

Complications

Severe cases of pectus excavatum can compress the heart and lungs or 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. This can cause symptoms such as exercise intolerance, shortness of breath, rapid heart rate, and chest pain or pressure.

Self-image problems

Many people who have pectus excavatum will 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 where their chest can be seen, such as swimming. They may also avoid clothing that makes the indentation in their chests more difficult to camouflage.

Diagnosis

Pectus excavatum can usually be diagnosed simply by examining the chest. 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.
• CT scan or MRI. These tests may be used to help determine the severity of the pectus excavatum and whether the heart or lungs are being compressed. CT scans and MRIs take many images 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. An echocardiogram also gives your doctor a look at how the chest wall may be affecting heart function and the flow of blood through the heart.
• Lung function tests. These types of tests measure the amount of air your lungs can hold and how quickly you can empty your lungs.
• Exercise function test. This test monitors how well your heart and lungs function while you exercise, usually on a bike or treadmill.

Treatment

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 the depression of your breastbone isn't causing any symptoms but you're unhappy with how it looks, you could talk to a surgeon about having a silicone insert — similar to a breast implant — placed under your skin to fill in that space.

Repair surgery

The two most common surgical procedures to repair pectus excavatum are known by the names of the surgeons who first developed them:

• Nuss procedure. This minimally invasive procedure uses small incisions placed on each side of the chest. 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 or three years.
• Ravitch technique. This older procedure involves a much larger incision down the center of the chest. The surgeon removes the deformed cartilage attaching the ribs to the lower breastbone and then fixes the breastbone into a more normal position with surgical hardware, such as a metal strut or mesh supports. These supports are removed after 12 months.

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. Although most surgeries for pectus excavatum are performed around the growth spurt at puberty, many adults also have benefitted from pectus excavatum repair.

There are many options for pain control after surgery to help improve recovery. Cryoablation temporarily freezes the nerves to block pain after surgery and can help with recovery and decrease postoperative pain for 4 to 6 weeks.

Potential future treatments

The FDA has recently approved the use of suction cups to help raise the depressed breastbone in younger patients developing pectus. Used for 20 to 30 minutes daily, this is a potential treatment to prevent the worsening of pectus in children as they grow.

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.

Preparing for an appointment

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

What you can do

You may want to write a list that includes:

• Detailed descriptions of your 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?