Pectus Excavatum

What is pectus excavatum?

Pectus excavatum is a growth abnormality of the chest wall in which the cartilage connecting the rib bones to the breastbone (or sternum) sinks down or inward, causing a sunken in look. It is the most common chest wall deformity occurring more often in males than females. 

What causes pectus excavatum?

Although we don’t know exactly what causes pectus excavatum, it is thought that the cartilages grow differently or unusually and this pushes the sternum inward, creating the sunken look. The chest wall deformity can also be linked to other conditions. Some people also have abnormal curvatures of the spine (like scoliosis), and others with pectus excavatum may have certain connective tissue diagnoses (like Marfan syndrome) and may need further evaluation, including genetic testing or testing of their heart.

Does pectus excavatum get worse with age?

Pectus excavatum can be present at birth or develop early in life for some children.  Severity will vary from person to person but typically when a person with pectus excavatum goes through puberty, the appearance of the chest wall becomes more sunken in. Although it is not common, some patients notice an improvement in their chest appearance as their muscles develop more around the area during puberty.

What are symptoms of pectus excavatum?

Outside of the physical appearance of a sunken chest wall, many patients do not have other symptoms. For those that do experience other symptoms, they can range from mild to severe and may include:

  • breathing problems
  • difficulty with exercise
  • chest pain
  • tiredness
  • a rapid heartbeat
  • wheezing or coughing

While some people may not care about the look of their chest, others struggle with body image concerns that can interfere with life. They may avoid taking off their shirt in public (like when swimming) or adjust the way they dress or hold themselves so other people cannot tell their chest is sunken.

It is common for people with pectus excavatum to have posture problems which can include forward slouching shoulders, a curved forward upper spine (kyphosis) and a stomach that sticks out. This posture can make the chest look worse than it is. Physical therapy can often help with posture and your child may meet with a physical therapist before surgery.

What are complications of pectus excavatum?

Most with pectus excavatum have no problems with their heart and lungs during normal, and even competitive, activities. However, there are some people with severe pectus excavatum that may experience heart and lung concerns due to the breastbone pushing one or more organs over to one side of the body. This is rare and, in some people, this will get better after surgery.

How is pectus excavatum diagnosed?

A physical examination by your doctor is used to make the diagnosis of pectus excavatum. Most people only need a two-view chest x-ray to calculate a Haller index which is a measurement to tell how severe the pectus excavatum is.

In special circumstances, your child may get:

  • a chest computerized tomography (CT) scan
  • an electrocardiogram (EKG) to record the heart’s electrical activity
  • an echocardiogram, or ultrasound of the heart
  • tests of lung function

These are often unnecessary and may not affect the decision for surgery. At Mott, we also take photos including 3D surface scanning to help follow your child’s progress over time.

How do you treat pectus excavatum?

Not every patient requires surgery but it’s important to know that without an intervention the appearance of the chest wall is unlikely to improve over time.  Even if surgery is recommended for your child, the decision is still up to your family on whether you’d like to proceed.

The first step to help guide our surgery recommendation is to calculate a Haller index. This a measurement of how wide the chest is compared to the deepest part of the sunken chest. The higher the number, the more “severe” the pectus excavatum. Corrective surgery is considered when a Haller index is great than or equal to 3.25. However, it’s important to know the severity may not correlate with symptoms.

Haller index ranges:

  • Normal chest: less than 2.0
  • Mild excavatum: 2.0 – 3.2
  • Moderate excavatum: 3.2 – 3.5
  • Severe excavatum: greater than 3.5

Your child’s first clinic visit is often informational. Patients and families usually take time to think about whether they want to pursue surgery and set up a follow-up visit to talk more about it. There is no rush in deciding if surgery is right for your child.

There is one non-surgical option you can consider for treatment called “the vacuum bell.” It is currently under investigational study and not offered at Mott. It requires extended suction to be applied to the chest and, while it does avoid surgery if effective, it is a more extended therapy. It is only suggested to improve mild pectus excavatum so not all patients are good candidates.

Even if you do not have surgery, exercises to improve posture are very important. Additionally, we recommend your child consider using a breathing resistance trainer such as Expand-A-Lung or POWERbreathe. These can help your child overcome anxiety and work through any sports or activity limitations they may experience. If your child does select surgery, the device can also help with recovery.

What are the surgical options to correct pectus excavatum?

There are two surgical options we offer patients at Mott.  Your child’s surgeon will provide a recommendation of which procedure they believe is best for your child based on their anatomy and other concerns. The two surgical options are:

  • Nuss procedure: a minimally invasive surgery that places a longer steel bar (a pectus bar) between the ribs and under the sternum through two small incisions on each side of the chest. The bar instantly pushes your child’s sternum forward and is in place around three years.  This prevents the chest from sinking back in while they continue to grow. The Nuss procedure is the most common repair performed at Mott.
  • Modified Ravitch procedure: a larger incision across the front of the chest is made to remove the abnormal cartilages causing the defect and place a shorter bar underneath. The bar is in place around three to six months while the cartilage regrows to prevent your child’s chest from sinking back in. This procedure is sometimes chosen when someone has a more severe pectus excavatum, when the breastbone is very rotated, or with severe lower rib flaring. However, others chose this procedure if they do not want to leave the Nuss bar in place for 3 years.

Because care is individualized for each patient at Mott, we can sometimes combine parts of the Ravitch with the Nuss procedure for a hybrid approach.

Why choose Mott for care of pectus excavatum?

Our experienced pediatric surgeons take great interest in patients with pectus excavatum and continuously strive to use novel techniques to improve outcomes. C.S. Mott Children’s Hospital offers optimal pain management when surgically repairing pectus excavatum. Using cryoablation, we apply extremely cold gas to freeze the nerves around the surgical area to make the surgery site numb. This has helped decrease the use of narcotics and the length of stay in the hospital. Patients also seem to be more active after surgery earlier because they have less pain.

Making an appointment

If you would like to learn more about pectus excavatum repair or schedule an appointment with Pediatric Surgery, please call 734-936-5738.