Pectus Excavatum is the significant condition that causes an actual cave in the chest of a child. It is a common chest wall deformity that significantly affects the lives of children. Although it is primarily a cosmetic concern, it can also result in cardiovascular and respiratory problems if left untreated.

Introduction

Pectus Excavatum is a depression of the anterior chest causing a permanent indentation¹ It is also referred to as sunken or funnel chest.² The severity levels can be mild, moderate or severe based on how deep the indentation is, the symmetry of the chest and the breath of the deformity. It varies in shape also,¹ it can be 

1. A small cup-shaped, deep deformity
2. A large, saucer-shaped shallow deformity

It is usually visible at birth but becomes more prominent, especially at puberty which is when there is accelerated growth of the bones.¹ It usually affects about 4-5 ribs on each side of the chest resulting in unequal appearance of the chest.

About 90% of chest wall deformities are due to pectus excavatum occurring in about 1 in 300-400 children and is three times more common in males than females.² It has some impact on physical and emotional health especially on self-esteem and can result in body dysmorphia.^{3, 4}

Causes and risk factors

1. Genetic Factors: It can not yet be explained how this abnormal growth of the bones and cartilage involved occurs and no genetic link has been found to it. However, there is a 35% chance of occurrence if the defect is present in the family.⁵
2. Connective Tissue Disorders: It is associated with some connective tissue disorders, more commonly marfan syndrome and Ehlors Danlos syndrome.⁶
3. Environmental Factors
4. Gender Disparity: The condition is more common in males but the probability of having an accompanying spine deformity known as scoliosis is more common with females.⁷

Clinical features

The most present clinical feature is the concave appearance of the chest. Some children may present with irregular breathing patterns in severe cases where the ribs are compressed and there is barely enough space for the lungs or heart to function.

In neonates, these chests may depress further when they perform actions that increase pressure in the abdomen like crying, laughing or breathing. Older children may have a semblance of a pot belly due to the protrusion of the lower ribs.

Other features include shortness of breath, Intermittent chest pain, hooked shoulders, a broad thin chest and occasionally, a curved spine. They could also have irregular or fast heart beats. It could also affect their daily activities causing exercise intolerance.

Diagnosis

Diagnosis is primarily by physical examination but can be further confirmed with chest x rays.

Other tests may be conducted based on the presence of complications. These tests include

• CT scan/MRI These would give a picture of the chest bones as well as the organs within the chest wall to show the extent of compression
• Pulmonary function tests to check the function of the lungs
• Echocardiogram which is an ultrasound of the heart to confirm if the heart world well enough
• Exercise stress testing to confirm how the child performs during exercise

Treatment 

The deformity may be left untreated if there are no complications. However, the decision to treat your child’s deformity could be due to presence of symptoms or for cosmetic reasons.

Observation and monitoring

Non-surgical procedures

Physical therapy

There has been no concrete evidence to show that physical therapy works for this condition. Surgical interventions are mostly used. The surgical interventions are mostly advised if the patient has cardiac or lung complications or for cosmesis. The goal is to improve the chest appearance 

Vacuum bell device

This device is used for children that do not want surgery. The doctor will place a bell shaped rubber device on your child’s chest and connect it to a pump that causes a force strong enough to pull the depressed area of the chest. It can be used everyday for about two hours. This device can be uncomfortable for your child but may not cause pain. It is usually effective after 1-2 years if used consistently but the effect may not be sustained.

Surgical procedures

Nuss procedure

Also known as minimally invasive repair of pectus excavatum and is the commonest procedure used to treat this condition. It takes about 2-3 years for the deformity to resolve. Before the surgery, the doctor will measure your child’s chest to determine the length of the bar to use. You may be asked to restrict your child’s food or water intake hours before the surgery and antibiotics may be given, these will help prevent complications from surgery.  Small cuts are made on the chest walls by the surgeon and one or more curved metal bars are inserted to lift the ribs and breast one, a bar may be inserted also to keep the bones in place. The bars will be removed after the deformity has resolved. Your child may experience some pain or may be uncomfortable after the procedure.

Ravitch procedure

Also known as open procedure. Children still have the ability to regrow their cartilage which is what this procedure requires. During the procedure, the surgeon takes out the cartilages, which are soft tissue that connects your child’s ribs to the breast bone, and inserts bars to support the chest while the cartilages grow back. The support is removed after 6 months. Your child may also experience pain and discomfort after this procedure.

Considerations for age and severity

Prognosis and complications

Impact on quality of life 

Asymptomatic Pectus Excavatum does not affect QoL largely. However, your child may have body positivity issues which may affect their social life. In more severe cases, where the heart and lungs are affected,  your child’s daily life could be affected. Your child may not be able to participate in strenuous physical activities and it may affect their overall performance.. In such situations, it is recommended to see a pediatrician and may require surgery.

Summary

Surgery has been shown to increase body positivity and also the physical symptoms associated with pectus excavatum