Pectus Excavatum

  • What is pectus excavatum

    pectus excavatumPectus excavatum is a congenital chest wall deformity that is caused by an overgrowth of the cartilage that connects the ribs to the breastbone. This overgrowth causes a depression of the sternum and the chest has a “sunken in” or “funnel chest” appearance. The condition affects more boys than girls. It is often present at birth but becomes more noticeable during times of rapid growth, such as puberty.

  • Symptoms

    Pectus excavatum can range from mild to severe. Those with a mild condition often do not have symptoms. Those with moderate-to-severe condition may have symptoms such as shortness of breath, fatigue, exercise intolerance/limitations and chest pain. With a severe case of pectus excavatum, there can be compression on the heart and lungs. Pectus excavatum may also be associated with scoliosis in some children. Children with pectus excavatum may experience some negative effects on their self-esteem due to the appearance of the chest.

  • Causes

    There is no known cause for pectus excavatum. It can sometimes run in families — which suggests genetics may play a role. Pectus excavatum can also be associated with connective tissue disorders such as Marfan syndrome.

  • Diagnosis

    Pectus excavatum is diagnosed by a thorough health history and physical examination. A CT scan of the chest is essential as it provides the Haller index. The Haller index is the ratio between the transverse chest diameter (measurement from one side of the ribcage to the other) and the anteroposterior diameter (measurement from the breastbone to the spinal cord) of the chest.

    A normal chest ratio is approximately 2.5 and an index over 3.2 is often defined as severe and eligible for the Nuss procedure. The chest CT will also show any displacement or compression of the heart.

    Some other tests such as pulmonary function tests or an echocardiogram may be used to determine the extent of heart and lung compression.

  • Treatment of pectus excavatum

    The treatment of pectus excavatum is dependent upon the severity of the defect and your child’s symptoms. In most cases, surgery is not indicated. At CHOP, we offer two different treatments for pectus excavatum. We may recommend observation for mild to moderate cases and surgery for more severe or complex cases.

    • The Nuss procedure is a minimally invasive technique for surgical repair that involves placement of a concave steel bar under the sternum. At CHOP, the Nuss procedure is the most common surgical procedure for pectus excavatum.
    • For those who are not candidates for the Nuss procedure, the Ravitch procedure can be used for correction.

    Although surgery may be recommended for your child, the decision to move forward with the procedure is up to your child and family.

    Depending on your insurance, you may need a prior authorization prior to your clinic visits. When you schedule your appointment, you will be notified if you need a prior authorization/referral. Your primary care physician can help you obtain a referral/prior authorization for your clinic visit. If surgery is recommended for your child, a member of our team will assist you in obtaining any authorizations needed.

  • Follow-up care

    After being treated and discharged from the hospital, your child will follow up in the general surgery clinic in 2-4 weeks. Your child’s surgeon or nurse practitioner will go over pain management and activity restrictions, and any other information you may need to care for your child at home. For more information about what to expect after surgery, read more about the Nuss procedure.

    While it is not mandatory to wear a Medical Alert bracelet after surgical correction of pectus excavatum, it is strongly recommended. Information can be provided to you at a post-operative visit on obtaining a Medical Alert bracelet. The inscription on the bracelet should read “steel bar in chest, CPR more force, cardioversion ant/post placement.”

    Having a steel bar in the chest raises several common questions about daily activities. Here are a few things you should know:

    • The bar should not set off metal detectors in the airport. We can provide documentation of the bar if necessary.
    • Antibiotics are not required prior to dental procedures while the bar is in place.
    • If needed, your child can still receive CPR while the bar is in place. Chest compressions should be done with more force due to the bar placement. An AED can also be used with the bar in place; however, the paddle placement will be different. One paddle should be placed on the front of the chest and the other should be on the back.

Reviewed by N. Scott Adzick, MD, MMM, FACS, FAAP, Mary Kate Klarich, MSN, CRNP, Natalie Walker, RN, MSN, CRNP, Gina Kroeplin, MSN, CRNP on April 01, 2012