Sunken (Funnel) Chest. How to Fix It?

Pectus excavatum occurs when there is abnormal chest wall formation, leading to depression of the sternum (breastbone) and ribs; it is also known as "funnel chest” or “sunken chest.” The Pectus excavatum occurs from an overgrowth of connective tissue between the ribs and sternum, leading to inward chest wall development.

Pectus excavatum can lead to heart and lung issues due to compression. The only treatment for pectus excavatum is surgical.

Pectus excavatum differs from pectus carinatum. In pectus excavatum, there is an inward movement of the sternum (breastbone) and ribs, while pectus carinatum has an outward (forward) movement of the sternum and ribs.

How common is pectus excavatum?

Pectus excavatum occurs in 1 of every 300-400 children; it affects boys three times more often than girls.

What are the structures involved in the pectus excavatum?

As shown in diagram 1, the pectus excavatum causes inward deviation of the sternum and ribs. The two pictures on the left are cross sections: the one on the upper left is a normal chest, while the one on the lower left is a chest with pectus excavatum.

The usually affected ribs are #3 to #7 of our 12 ribs. Even though pectus excavatum can occur evenly on both sides (symmetrical), it is usually formed unevenly on the two sides (asymmetrical).

Unlike pectus carinatum, which does not usually affect the heart and lungs, pectus excavatum does affect the heart and lungs due to the decreased thoracic space.

What causes pectus excavatum?

What exactly causes pectus excavatum is not known; however, there appears to be a genetic component. Not only is pectus excavatum associated with other genetic disorders, such as Marfan syndrome and Noonan syndrome, but it is also seen in the family members of more than 40% of cases.

What are the symptoms of pectus excavatum?

One of the most common symptoms is an inability to exercise normally: shortness of breath, fatigue, and palpitations (a sensation that your heart is beating fast or pounding). Furthermore, there can be exercise-induced chest pain, asthma, or frequent respiratory tract infections.

In addition to these physical symptoms, there can be psychological side effects, including uneasiness with appearance, poor self-esteem, and depression.

How is the diagnosis made for pectus excavatum?

The history should elicit the symptoms mentioned above.

A physical examination of the chest will show a sunken sternum. In addition, there can be mid-back scoliosis and uneven shoulders.

If the heart or lungs are affected, the examining physician may hear a heart murmur or decreased breath sounds.

Imaging studies will start with a 2-view chest x-ray: AP (front to back) and lateral (sideways) views. The lateral view is more valuable in viewing the sunken sternum (and ribs), but both allow visualization of the heart and lungs.

If more detailed radiological information is needed, your physician may order a computed tomography (CT or CAT) scan, which allows three-dimensional viewing. In addition, a magnetic resonance imaging (MRI) test can be done for a detailed evaluation of soft tissue structures.

Special tests may be done in cases of pectus excavatum.

Pulmonary function tests (spirometry) evaluate lung function: inhaled volume, exhaled volume, and exhalation rate are recorded.

An electrocardiogram (EKG) shows the electrical conduction in the heart. If the heart has deviated to one side, it should show on the EKG.

An echocardiogram (echo) is an ultrasound of the heat. It shows the heart pumping in real time, allowing the heart’s muscles and valves to be evaluated.

A cardiopulmonary exercise test (CPET or CPEX) is helpful for heart and lung evaluation. This test differs from a routing stress test; both collect information about the heart, but the CPEX also gathers information about the lungs.

What is the treatment for pectus excavatum?

Unlike pectus carinatum, which can be treated conservatively by non-surgical methods, the only treatment for pectus excavatum is surgery.

Most people who undergo pectus excavatum surgery are aged 13-22: surgical treatment is not done until after the growth spurt of puberty. In addition, most of the time, the primary decision to perform surgery is due to reduced cardiopulmonary functioning and not because of cosmetic reasons.

There are two main surgical procedures for treating pectus excavatum.

I. The Ravitch procedure was invented in 1949 by Dr. Mark Ravitch. It is considered a more invasive procedure since there is a large incision (surgical cut), placing it into an "open" procedure category. Once the incision is done, the rib's cartilage is removed, and metallic hardware is set to move the sternum back into its normal position.

The metal hardware can be either a bar or plates (with screws). The bar has to be surgically removed a year later, but the plates (with screws) do not require surgical removal.

II. The Nuss procedure is less invasive since it only requires two small incisions that allow a scope to enter the chest cavity. A curved metal bar called a Nuss bar is inserted using this scope. The Nuss bar presses the sternum forward, and then it is removed three years later.

Because the Nuss procedure is less invasive than the Ravitch procedure, the recovery is shorter.