Pectus Excavatum Diagnosis and Treatment at the Center for Chest Wall Deformities

An example of pectus excavatum

Pectus excavatum, also known as hollowed chest, sunken chest or funnel chest, is the most common chest wall malformation seen in children.

Learn more about pectus excavatum 

Diagnosis

Patients at our center are diagnosed by a thorough health history and physical examination, and will complete a series of diagnostic tests, including:

• A CT scan or MRI of the chest: This measures the the pectus excavatum severity score, known as the Haller index. The index compares the depth of the chest cavity beneath the sternum to the width of the chest cavity (from right to left). Normal ratio of width to depth is about 2.5 to 1. Any calculation greater than 3.25 is considered a moderate to severe defect.
• An echocardiogram ultrasound to evaluate the heart structure and function.
• Pulmonary function tests (PFTs) to evaluate lung function.
• Metal allergy testing for the bar that is used in certain treatments; patients with an allergy to nickel will require a special type of bar.

Surgery

Our team of expert surgeons at Johns Hopkins Children's Center will work with families to evaluate each individual patient and determine the best treatment option.

If surgery is necessary, it will typically occur when a patient is between 14 and 18 years of age. Children under 14 may be candidates for surgery, unless there are other indications, such as the risk of thoracic dystrophy, which can limit appropriate growth of the chest wall.

Moderate and severe cases of pectus excavatum often require surgical correction. Our surgeons use a minimally invasive repair called the Nuss procedure.

Nuss procedure

Led by our renowned pediatric surgeons, this procedure involves two small incisions made on each side of the chest and the placement of one or more stabilizing metal bars just inside the ribcage to move the sternum forward.

The bars are shaped to the patient during the operation and remain in place for two to three years to allow the ribs to adjust to the new shape of the chest.

Modified Ravitch procedure

Led by our renowned pediatric surgeons, this procedure Involves an incision across the chest and removal of the cartilage causing the defect. The sternum is then placed in the normal position. A small bar may be used under the sternum to hold it in the desired position.

The cartilage will regenerate over the next four to six weeks, causing the sternum to be in a fixed position. A small drain may be placed at the site of the operation to prevent a fluid collection.

Surgery Recovery

Our team has developed an enhanced recovery after surgery (ERAS) protocol focused on patient comfort and a quick return to activity. This protocol was developed in conjunction with our pediatric pain team to help minimize use of narcotics or opioid medications. Most patients spend one to three nights in the hospital and are able to resume their full activities, including sports and weightlifting, by three months.

Your child's surgical team will work with you and your family to make sure you fully understand your child's treatment plan and recovery needs. We have also created a helpful discharge packet for you to reference that provides information on how to recover at home following the Nuss procedure.

Pain Management

Our anesthesia and pain medicine specialists work with you and your child before and after surgery to provide a patient-centered, individualized plan to address pain control. Our patients typically have a patient-controlled analgesia (PCA) device for postoperative pain management. We also use other medications to help manage pain in order to ensure that patients stay comfortable.

During surgery, most of our patients undergo cryoablation, which temporarily freezes the nerves in the chest wall to block pain after surgery. Typically, the chest will feel numb or have decreased sensation up to three months following surgery. Other pain modalities that may be used during surgery for pain control are nerve blocks and local anesthetics. 

Pectus Carinatum Diagnosis and Treatment at the Center for Chest Wall Deformities

Pectus carinatum, commonly referred to as pigeon chest, is a chest wall malformation in which the sternum and ribs push in an outward direction.

Learn more about pectus carinatum 

Diagnosis

Patients at our center are diagnosed by a chest X-ray or CT chest scan to evaluate the extent of the pectus defect and the internal chest anatomy and structure.

Treatment

Our team of expert surgeons at Johns Hopkins Children's Center will work with families to evaluate each individual and determine the best treatment option.

Depending on the severity of the condition, the child will be treated in one of two ways:

Chest wall bracing

If your child’s condition is mild or moderate, bracing will likely be recommended. The device wraps around the chest, adding mild pressure on the portion of the chest that sticks out, and the breastbone will slowly shift into its proper place. We will consult with you and your child to recommend a wear schedule, which can range from 12 or more hours a day for several months. Once the desired degree of correction has been achieved, patients will only need to wear the brace at night in order to maintain the corrected shape.

Modified Ravitch procedure

Led by expert pediatric surgeons, this procedure involves an incision across the chest and removal of the cartilage causing the defect. The sternum is then placed in the normal position. A small bar may be used under the sternum to hold it in the desired position.

The cartilage will regenerate over the next four to six weeks, causing the sternum to be in a fixed position. A small drain may be placed at the site of the operation to prevent fluid collection.