The most common chest wall deformity, pectus excavatum gives the appearance of a sunken chest or breastbone.

What is pectus excavatum?

Translated literally as “hollowed chest,” pectus excavatum, referred to as sunken chest or funnel chest, is the most common chest wall deformity seen in children. An overgrowth of the rib cartilages before and after birth causes the characteristic depression of the sternum (breastbone).  This defect commonly worsens during puberty until age 18, when most of the growth spurt is complete.

Pectus Excavatum Causes

The exact cause of pectus excavatum is unknown. Recent information suggests the condition may be linked to:

• A genetic component (pectus excavatum may be more common in adolescents who have another family member with the condition)
• An imbalanced growth of the sternum and ribs
• Musculoskeletal disorders such as scoliosis, Ehlers-Danlos syndrome, Marfan syndrome or homocystinuria, which suggests abnormal connective tissue (however, most patients with pectus excavatum do not have musculoskeletal disorders)

Pectus Excavatum Symptoms

Children with pectus excavatum usually have no symptoms, but the defect becomes more pronounced with the growth of the chest during puberty. Depending on the seriousness of the defect, pectus excavatum may cause poor posture with slumped shoulders and a protruding abdomen or “potbelly,” as well as problems with bone growth and alignment later in life.

Some teenagers with pectus excavatum complain of fatigue and shortness of breath when exerting energy, and pain at the front of the chest.

In severe cases, pectus excavatum shifts the heart to the left side of the chest and compresses the lungs, limiting the child’s ability to take deep breaths.

Diagnosis of Pectus Excavatum

Pectus excavatum is measured primarily in two ways:

1. Using modified percent depth (MPD), which measures how sunken the chest is compared to the nipple line (the MPD is taken during a physical exam and can be used to monitor progression of the abnormality over time; an MPD greater than 11% indicates the abnormality is severe and may require surgical repair, which is recommended for children with cases that are moderate to severe)

2. Using CT scanning to calculate the Haller index, a measurement that compares the depth of the chest cavity beneath the sternum to the width of the chest cavity, from right to left (the normal ratio of width to depth is about 2.5 to 1; a ratio of 3.25 to 1 is used to signify a severe deformity, and surgical correction may be recommended)

A doctor may order additional tests, including:

• A chest MRI to determine the severity and degree of compression of the heart and lungs
• An echocardiogram, which tests the heart’s ability to function
• Exercise stress tests to determine exercise tolerance
• Pulmonary function tests, which determine lung function

Pectus Excavatum Surgery

Safe repair of pectus excavatum is best performed in children over age 5. The preferred age for repair is about 14 — the operation is easier and recovery is shorter in this age group because in most cases, the majority of the pubertal growth spurt has passed, but the rib bones are still not completely formed. Performing surgery at this age allows the chest wall to re-form into a more normal shape as the child grows after the repair. Older adolescents and adults also report good results with repair.

There are two surgical operations to repair pectus excavatum:

Nuss Procedure

During the Nuss procedure, one or more stabilizing metal bars are placed just inside the rib cage to move the sternum forward. The bars are shaped to the child’s chest wall during the operation and typically remain in place for three years to allow the ribs to adjust to the new shape of the chest. The bars are removed during an outpatient procedure.

Ravitch Technique

With the Ravitch procedure, surgical repair is performed through a horizontal incision across the middle of the child’s chest. The surgeon repairs and reshapes the ribs, breastbone and cartilage that make up the chest wall, and may also place a bar or bars into the chest to ensure that it keeps its proper position. In most cases, the bar will stay in place for six to 24 months, when a surgeon will remove it.

Pain Relief After Surgery

Cryoablation is used to dramatically reduce pain after the procedure. A surgeon freezes the nerves above and below the bar on each side of the chest to temporarily decrease pain transmission through these nerves for three months following surgery. Cryoablation has also resulted in decreased opioid use and their side effects. It has also led to earlier discharge from the hospital.

Recovery from Surgery

Improvement in the chest wall varies and depends on the severity of the condition. Usually, children recovering from surgery for pectus excavatum stay in the hospital one to three days. During this time, a pain management plan may be created.

To prevent the bar or bars from moving during the early recovery phase, it is very important to follow the surgeon’s instructions about returning to activity. It is typical to refrain from physical activities for several weeks to several months following surgery.

Nonsurgical Treatments for Pectus Excavatum

For cases of mild pectus excavatum, a vacuum bell device is used. This nonsurgical treatment requires a bell device to be placed over the child’s chest. The bells connect to a pump that sucks the air out of the device, creating a vacuum that pulls the chest forward. With time, the chest wall will stay in place on its own.