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The University of Chicago Medicine - Comer Children's Hospital

Pectus Excavatum

Pectus excavatum (also known as sunken chest or funnel chest) occurs when the cartilage and bones of the sternum and ribs do not properly form. The cartilage and the bones are instead pushed inward, leading to a "caved in" appearance of the chest. The condition often goes unnoticed until puberty, when rapid growth and development may intensify the appearance of the defect.

Some adolescents with pectus excavatum do not experience any symptoms and many patients will not require surgical correction. When symptoms are present, patients may complain of pain in the chest, back and elsewhere, as well as shortness of breath and early fatigue. This is because pectus deformities can affect function of the heart and lungs. There may also be psychological and social implications because it affects the appearance of the chest wall.

In some patients there can be a genetic component to pectus excavatum. It may be more common in adolescents who have another family member with the condition. In addition, some patients with pectus deformities also have inherited connective tissue disorders such as Marfan syndrome, homocystinuria or Ehlers-Danlos syndrome.

Diagnostic Testing

  • CT Chest: Evaluation of the internal chest anatomy and structure. A CT chest also allows physicians to calculate the Haller Index, an indicator of the severity of the pectus excavatum deformity.
  • Echocardiogram: Ultrasound evaluation of the heart structure and function.
  • Pulmonary Function Tests (PFTs): Evaluation of lung function.
  • Metal Allergy Testing: Patients with a allergy to nickel will require a special type of bar be placed.

Treatment

Moderate and severe cases of pectus excavatum often require surgical correction. The minimally invasive Nuss procedure and the modified (small scar) Ravitch procedure are the most commonly used approaches. The team of experts in the Chest Wall Deformity Program at the University of Chicago Medicine Comer Children's Hospital works with families to evaluate each individual case and determine the best treatment option.

If surgery is necessary, it typically occurs when a patient is between 14 and 18 years of age. Children under 14 or older than 18 may also be candidates, but very young children usually are not candidates unless there are other indications, such as the risk of thoracic dystrophy, which can limit the appropriate growth of the chest wall.

Thoracoscopic Nuss Procedure

A minimally invasive approach to pectus excavatum repairs, the Nuss procedure offers faster recovery time and less scaring than traditional, open surgeries. During the Nuss procedure, a surgeon makes a small incision on either side of the chest and then custom fits a curved steel or titanium bar for the patient’s chest wall. The bar is introduced through the incisions and is tunneled under the sternum. The bar is rotated into place, and elevates the sternum thereby correcting the defect. On occasion, two bars are required to fully correct the pectus deformity. During the procedure, a small camera (thoracoscope) in both chest cavities monitors bar placement to decrease the risk of injury to surrounding structures.

The bar usually stays in place for two years or more. The operation to remove the bar is performed on an outpatient basis.

Ravitch Technique

During the Ravitch procedure, an incision is made along the chest wall over the sternum. Surgeons at Comer Children's use a modified Ravitch approach, which involves making incisions as small as possible. A surgeon will remove cartilage around the area of deformity, detach the sternum and then reposition it. Sometimes, a small metal bar is also placed under the sternum to support it in the desired position. The bar is usually left in place for about two years until the cartilage can solidify in the new corrected position. The operation to remove the bar is performed on an outpatient basis.