Pectus Excavatum

What are the signs and symptoms of pectus excavatum?

The chest wall depression tends to get worse over time until late adolescence. Children with pectus excavatum may have no symptoms, or they may have mild signs and symptoms, which can include:

• Decreased tolerance to exercise
• Fatigue
• Heart murmur
• Rapid heartbeat or palpitations
• Recurrent respiratory infections
• Wheezing or coughing
• Chest pain

What tests are used to diagnose pectus excavatum?

There are several tests that the doctor may use to evaluate your child. These can help determine the severity of your child’s pectus excavatum and show if it is impacting the organs within the chest.

• Chest X-ray
• CT scan
• Electrocardiogram (EKG)
• Echocardiogram (ECHO)
• Lung function tests
• MRI

What to expect from pectus excavatum tests

• A chest X-ray provides pictures of the breastbone and ribs. It may show if your child’s heart is displaced. It can also be used to determine the severity of the pectus excavatum. An X-ray is not painful.
• A CT scan may help determine the severity of the pectus excavatum. CT scans use radiation to take pictures of the inside of the body from many different angles so your physicians can better understand the chest deformity. Your child will be awake during this procedure. We may place an IV (small catheter) in their arm so we can inject contrast fluid during the exam. Your child will lie down on a table that moves in and out of the machine as the camera takes pictures.
• An EKG shows if your child’s heart has a normal or abnormal rhythm. It also evaluates how electricity travels through the heart. This test is painless. Your child will have stickers placed on their chest and electric leads attached to the stickers. It only takes a few minutes.
• An ECHO is an ultrasound of the heart. It measures how well it is functioning. The exam is not painful and does not take very long.
• A lung function test measures how well your child’s lungs work. It is painless. Your child will breathe into a small machine. The test is designed to measure the amount of air in the lungs, and how the lungs function by moving air in and out.
• An MRI is a type of imaging that uses a magnetic field and radio waves to create images of the inside of the body. Your child lies down on a table next to a machine (or tunnel) that looks like a big doughnut. An MRI technologist positions your child on the scanning table, then slides the table into the MRI tunnel. Your child will hear whirring, knocking and beeping noises while the images are taken. We provide earplugs and headphones to help with the noises. We make every effort to help your child feel comfortable without using anesthesia or sedation. However, some children can’t stay still for an MRI and they need sedation or anesthesia to help them relax or sleep during the procedure.

How do we make a diagnosis of pectus excavatum?

We make a diagnosis of pectus excavatum based on your child’s physical exam and imaging results.

Once your child’s CT scan is completed, your child’s doctor will calculate the Haller index. This is also known as the CT pectus index. A normal ratio is 1.50 to 2.0. A value higher than 2.0 indicates that a child has pectus excavatum. The higher the number, the more severe the deformity. A child with a CT pectus index greater than 3.2 means they have severe pectus excavatum and surgery can be considered.

How is pectus excavatum treated?

Mild cases

Mild cases of pectus excavatum may be managed with physical therapy and exercises that improve your child’s posture and the muscles of the chest, although the chest depression will not change.

Moderate to severe cases

In cases that are moderate to severe, your surgeon may recommend a surgical procedure that will help correct the deformity. There are two main types of surgery that are used to correct pectus excavatum:

• Nuss procedure: The most common procedure is the Nuss procedure. Your child will go to sleep with anesthesia and will not remember the procedure. The surgeon will make small incisions on either side of the chest and pass a metal bar underneath the breastbone. The bar will help move the breastbone to a more normal position. It will stay in place for two to four years, and then the surgeon will remove the bar. After the procedure, your child will stay in the hospital for several days for help with pain control and ensure that the lungs and heart have not been affected by the procedure.
• Ravitch procedure: Another option is the Ravitch procedure. Your child will go to sleep with anesthesia and will not remember the procedure. The surgeon will make an incision across the center of the chest and reshape the cartilage of the ribs. If needed, the surgeon may need to place one or several bars in the chest to correct the shape. These bars are removed in 6 to 12 months. The surgeon will also place one or more drains. Your child may also need a chest tube. After the procedure, your child will stay in the hospital for several days for help with pain control and ensure that their lungs and heart have not been affected by the procedure.

After either procedure, your child will have follow-up visits with the surgeon to ensure that they are healing well and their chest is responding appropriately to surgery.

Why choose us for the treatment of pectus excavatum?

The pediatric surgeons at Children’s Hospital Colorado are experienced in evaluating and treating pectus excavatum, both through surgery and through more conservative management. Our teams understand how pectus excavatum can affect your child physically and psychologically. We will walk you through the necessary steps of diagnosis and all the available treatment options. We will continue a relationship with your child in the following years to ensure that they respond well to treatment and have the best outcome possible.

Helpful resources

The American Pediatric Surgical Association works to ensure optimal pediatric surgical care of patients and their families, to promote excellence in the field and to foster a vibrant and viable community of pediatric surgeons.