Pectus Excavatum

Causes and Symptoms of Pectus Excavatum

Pectus excavatum affects about one in every 300 to 400 children. The condition can run in families and often occurs in children with Marfan syndrome or other connective tissue disorders. It can affect children of either sex but occurs more frequently in boys. Pectus excavatum can be detected as early as 2 to 3 years old, but often symptoms will become more apparent or worsen during puberty, usually around ages 9 – 12 in girls and ages 11 – 15 in boys. The condition will usually stabilize and not worsen after a child has finished growing.

In children with pectus excavatum, abnormal growth, rotation and lengthening of cartilage in the ribs causes the sternum, or breastbone, to become sunken or concave. It can also cause the lower ribs to flare out. Symptoms can include:

• Shortness of breath
• Chest pain
• Fainting
• Heart palpitations or other cardiac irregularities

Additionally, the physical appearance that pectus excavatum causes can often lead body-image issues and depression in children, adolescents and young adults.

Diagnosing Pectus Excavatum

To diagnose pectus excavatum, your child’s physician will conduct a full physical exam and evaluation. This includes imaging and cardiopulmonary function tests such as:

• Computed tomography (CT) scan
• Magnetic resonance imaging (MRI) scan
• Echocardiogram
• Electrocardiogram (EKG)
• Lung function tests
• Exercise assessments
• Evaluation for connective tissue disorders

A scale called the Haller index is used to assess the severity of pectus excavatum. Using measurements from your child’s CT or MRI, the index uses a ratio of the thoracic (chest) width and height to rate the condition as mild, moderate, severe or extreme.

Pectus Excavatum Treatment

Most mild cases of pectus excavatum will not require surgery. If symptoms are bothersome, physical therapy and exercises can be helpful. For moderate to extreme cases, there are two primary types of surgery that are used to treat pectus excavatum. These surgeries will usually not be performed until adolescence or later, starting around ages 13 – 15.

Modified Ravitch procedure: During this procedure, the surgeon makes an incision across the chest at the level of the indent and removes the rib cartilage above and below the sternum. They break the sternum, placing a rod beneath the sternum before sewing it back together. The procedure takes about four hours to perform. The rod will be removed in a later surgery after the condition has been fully corrected.

Nuss procedure: During this minimally invasive procedure, the surgeon makes two small incisions on either side of the chest. They slide a customized bar in upside down between the heart and the breastbone before flipping the bar over. The procedure takes about one hour. The bar will be removed about three years after the initial surgery.

Cryoblation for Pain Management

Previously, the Nuss procedure, while a shorter, less invasive surgery, was more painful than the Ravitch because it works by pushing the ribs out. However, in recent years surgeons have introduced the use of cryoblation during surgery. With this technique, some of the nerves near the ribs and sternum are frozen before the bar is inserted, greatly reducing postoperative pain. Cryoblation is so effective for pain relief that it has reduced the average hospital stay post-surgery from one week to two to three days.

Recovery from Pectus Excavatum Surgery

Your child can return to school and light activity around three weeks after surgery. For about six weeks, he or she should avoid activities that involve twisting of the torso, including driving. Patients are advised to restrict heavier activities for about nine months to a year. Your child will have a follow-up visit with their surgeon three weeks after surgery, and will have periodic check-ups for the next couple of years to monitor their progress and determine when the bar should be removed – usually about three years after the surgery.