What causes sunken chest? 6 possible conditions
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Pectus excavatum is a Latin term that means “hollowed chest.” People with this congenital condition have a distinctly sunken chest. A concave sternum (breastbone) may exist at birth, or it may develop later, usually during adolescence. Other common names include “cobbler’s chest,” “funnel chest,” and “sunken chest.”
About 37 percent of people with pectus excavatum also have a close relative with the condition. This suggests that it may be hereditary. Pectus excavatum is the most common chest wall anomaly among children.
In severe cases, it can interfere with the function of the heart and lungs. In mild cases, it can cause self-image problems. Some patients with this condition often avoid activities such as swimming that make hiding the condition difficult.
Patients with severe pectus excavatum may experience shortness of breath and chest pain. Surgery may be necessary to relieve discomfort and prevent heart and breathing abnormalities.
Physicians use chest X-rays or computed tomography (CT) scans to create images of the internal structures of the chest. These are used to measure the severity of the curvature. The Haller index is a standardized measurement used to calculate the severity of the condition.
The Haller index is calculated by dividing the width of the rib cage by the distance from the sternum to the spine. A normal index is about 2.5. An index greater than 3.25 is considered severe enough to warrant surgical correction. Patients have the option of doing nothing if the curvature is mild.
Surgery may be invasive or minimally invasive.
The Ravitch Procedure
The Ravitch procedure is an invasive surgical technique pioneered in the late 1940s. The technique involves opening the chest cavity with a wide horizontal incision. Small sections of rib cartilage are removed and the sternum is flattened.
Struts (metal bars) may be implanted to hold the altered cartilage and bones in place. Drains are placed at either side of the incision, and the incision is stitched back together. Struts can be removed, but are intended to remain in place indefinitely.
Complications are typically minimal, and a hospital stay of less than a week is common. In a study of 375 patients treated with this procedure at the UCLA School of Medicine over a 30-year period, more than 97 percent had a “very good” or “excellent” result (Fonkalsrud, et al. 2000).
The Nuss Procedure
The Nuss procedure was developed in the 1980s. It is a minimally invasive procedure. It involves making two small cuts on either side of the chest, slightly below the level of the nipples. A third small incision allows surgeons to insert a miniature camera, which is used to guide the insertion of a gently curved metal bar. The bar is rotated so it curves outward once it’s in place beneath the bones and cartilage of the upper ribcage. This forces the sternum outward.
A second bar may be attached perpendicular to the first to help keep the curved bar in place. The incisions are closed with stitches, and temporary drains are placed at or near the sites of the incisions. This technique requires no cutting or removal of cartilage or bone.
The metal bars are typically removed during an outpatient procedure about two years after the initial surgery in young patients. By then, correction is expected to be permanent. The bars may not be removed for three to five years or may be left in place permanently in adults. The procedure will work best in children, whose bones and cartilage are still growing.
Surgical correction has an excellent success rate. However, any surgical procedure involves some pain, the risk of infection, and the possibility that the correction will be less effective than expected. Scars are unavoidable, but are fairly minimal with the Nuss procedure.
Doctors are presently evaluating a new technique: the magnetic mini-mover procedure. This experimental procedure involves implanting a powerful magnet within the chest wall. A second magnet is attached to the outside of the chest. The magnets generate enough force to gradually remodel the sternum and ribs, forcing them outward. The external magnet is worn as a brace for a prescribed number of hours per day.
- Davis J. T., & Weinstein S. (2004, August). Repair of the pectus deformity: results of the Ravitch approach in the current era. The Annals of Thoracic Surgery, 78(2):421-426. Retrieved July 21, 2012 from http://www.ncbi.nlm.nih.gov/pubmed/15276489
- Fonkalsrud E. W., Dunn J. C., & Atkinson J. B. (2000, March). Repair of pectus excavatum deformities: 30 years of experience with 375 patients. Annals of Surgery, 231(3):443-448. Retrieved July 21, 2012, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1421017/?tool=pubmed http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1421017/?tool=pubmed
- Gurnett, C. A., Alaee, F., Bowcock, A., Kruse, L., Lenke, L. G., Bridwell, K. H., … Dobbs, M.B. (2009, January 15). Genetic linkage localizes an adolescent idiopathic scoliosis and pectus excavatum gene to chromosome 18 q. Spine, 34(2):E94-100. Retrieved July 21, 2012, from http://www.ncbi.nlm.nih.gov/pubmed/19139660
- Harrison, M. R., Curran, P. F., Jamshidi, R., Christensen, D., Bratton, B. J., Fechter, R., & Hirose, S. (2010, January). Magnetic mini-mover procedure for pectus excavatum II: Initial findings of a Food and Drug Administration-sponsored trial. Journal of Pediatric Surgery, 45(1):185-192. Retrieved July 21, 2012, from http://www.jpedsurg.org/article/S0022-3468(09)00814-8/fulltext http://www.jpedsurg.org/article/S0022-3468(09)00814-8/fulltext
- Harrison, M. R., Gonzales, K. D., Bratton, B. J., Christensen, D, Curran, P. F., Fechter, R., & Hirose, S. (2012, January). Magnetic mini-mover procedure for pectus excavatum III: Safety and efficacy in a Food and Drug Administration-sponsored clinical trial. Journal of Pediatric Surgery, 47(1):154-159. Retrieved July 21, 2012, from http://www.jpedsurg.org/article/S0022-3468(11)00909-2/abstract http://www.jpedsurg.org/article/S0022-3468(11)00909-2/abstract
- Hong, J. Y., Suh, S. W., Park, H. J., Kim, Y. H., Park, J. H., & Park, S. Y. (2011, December). Correlations of adolescent idiopathic scoliosis and pectus excavatum. Journal of Pediatric Orthopedics, 31(8):870-874. Retrieved July 21, 2012, from http://www.ncbi.nlm.nih.gov/pubmed/22101666
- Nasr, A., Fecteau, A., & Wales, P. W. (2010, May). Comparison of the Nuss and the Ravitch procedure for pectus excavatum repair: a meta-analysis. Journal of Pediatric Surgery, 45(5):880-886. Retrieved July 21, 2012, from http://www.jpedsurg.org/article/S0022-3468(10)00104-1/abstract http://www.jpedsurg.org/article/S0022-3468(10)00104-1/abstract
- Nuss, D., Kelly, R. E. Jr, Croitoru, D. P., & Katz, M. E. (1998, April). A 10-year review of a minimally invasive technique for the correction of pectus excavatum. Journal of Pediatric Surgery, 33(4):545-552. Retrieved July 21, 2012, from http://www.jpedsurg.org/article/S0022-3468(98)90314-1/abstract http://www.jpedsurg.org/article/S0022-3468(98)90314-1/abstract
- Rattan, A. S., Laor, T., Ryckman, F. C., & Brody, A. S. (2012, February) Pectus excavatum imaging: Enough but not too much. Pediatric Radiology. 40(2):168-172. Epub 2009 Oct 8. Retrieved July 21, 2012, from http://www.ncbi.nlm.nih.gov/pubmed/19813009
- Ravitch, M. M. (1949, April). The operative treatment of pectus excavatum. Annals of Surgery. 129(4):429-444. Retrieved July 21, 2012, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1514034/?tool=pubmed http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1514034/?tool=pubmed
- Shamberger, R. C. (1996, June). Congenital chest wall deformities. Current Problems in Surgery. 33(6):469-542.
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