Pectus excavatum is a congenital deformity of the bones and cartilage of the chest where several ribs and the breastbone (sternum) grow in an inward direction resulting in a sunken appearance of the center of the chest. As a result, the chest appears concave or caved-in, which is why the condition is also called "funnel chest" or "sunken chest". Frequently, it is associated with "flaring" of the lower ribs accentuating the appearance of the depth of the depression.

While no one knows exactly what causes pectus excavatum, we do know that sometimes the condition is found to run in families. People with pectus excavatum and other chest wall defects may also have another health condition, including:

Marfan syndrome: a genetic disorder affecting the connective tissue of the body involving bones, joints, and the heart

Poland syndrome: a rare birth defect marked by missing or underdeveloped muscles usually on one side of the upper chest which gives an appearance of asymmetry

Scoliosis: a disorder in which the spine twists leading to an abnormal curvature of the back

The main sign of pectus excavatum is a chest that looks sunken in. The depth of the depression may be asymmetrical such that one side appears deeper than the other. Most cases are diagnosed in the early teenage years during growth spurts and severe cases are usually offered surgical correction prior to adulthood. Uncorrected pectus excavatum tends to increase into adulthood and thus symptoms can worsen with age.  There are a significant portion of patients with pectus excavatum who have not undergone repair in childhood who seek treatment as adults due to worsening symptoms.  Some adult patients have symptoms either delayed or underappreciated until the fourth and fifth decade of life.  

Severe pectus excavatum causes a deep hollow in the chest that can put pressure on the lungs and heart, causing:

• Reduced exercise tolerance

• Limitations with physical activities

• Easy fatiguability

• Chest pain

• Rapid heartbeat or heart palpitations

• Frequent respiratory infections

• Coughing or wheezing

Doctors diagnose pectus excavatum based on a physical exam and a detailed medical history to determine what symptoms may be attributable to the defect. Specialized tests are often required to determine who should be offered surgical treatment and to look for any other associated medical conditions.

Routine tests for adults include:

• computed tomography (CT) scan to see the severity and degree of depression and compression of the heart and lungs with 3D modeling
  

• echocardiogram to test heart function

• pulmonary function tests to check lung volume

• exercise stress testing to measure exercise tolerance

Ravitch Procedure

The mainstay of surgical repair of pectus excavatum has been the Ravitch procedure initially performed in the 1940s and still performed today in a modified form. It is associated with lasting results, symptom improvement and patient satisfaction, but does require a larger incision in the middle of the chest. Usually a strut (metal bar) is placed at the time of surgery which must remain in place for 6-12 months (average).  Bar removal is performed in a separate short operation that does not require another hospitalization.

Nuss Procedure

Dr. Leah Backhus has specialized training for performing the Nuss procedure in adults. The Nuss procedure, also known as Minimally Invasive Repair of Pectus Excavatum (MIRPE), has the advantages of smaller incisions on the side of the chest rather than the middle, avoidance of cartilage or bone removal and has proved popular in the pediatric population. However, performing the Nuss procedure in adults requires modifications and the procedure may not be appropriate for all patients. Widespread use of the Nuss procedure in children has also resulted in an increased need for surgeons experienced in revisional surgery in adults following childhood repairs. In adults, often more than one Nuss bar are required to address the repair and each bar is recommended to remain in place for a minimum of 2 years. Bar removal is performed in a separate short operation that does not require another hospitalization.

Deciding which procedure is right for you requires a detailed examination and discussion with an expert in performing both. The decision is based on your individual anatomy, any prior surgery, and other clinical details such as patient age and other medical conditions. Ultimately, both the doctor and patient must determine which is the most appropriate procedure for each individual as well as what is most important to the patient.