Pectus Excavatum

What are the symptoms of pectus excavatum?

Symptoms of pectus excavatum are different at different ages. In infants, symptoms of pectus excavatum can include:

• a hollow depression in the chest that may be broad and shallow, deep and narrow, or irregular
• more rapid breathing than normal

In older children, symptoms of pectus excavatum can include:

• shortness of breath upon exertion or exercise
• chest pain
• a lateral curvature of the spine and absence of the curve of the upper back
• hooked shoulders
• a broad, thin chest

What causes pectus excavatum?

There is no known cause for pectus excavatum. While the majority of children with pectus excavatum don't have a family history, enough do to cause doctors to suspect that genes may play a significant role. Because of this, researchers are investigating a genetic component.

Are there any complications of pectus excavatum?

In cases of severe pectus excavatum, the sternum and ribs can press on a child’s heart and lungs. This usually only affects heart and lung function during extreme exercise and not usually in a major way.

Approximately 15 percent of children with pectus excavatum also develop scoliosis (curvature of the spine).

Pectus excavatum can be associated with connective tissue disorders such as Marfan syndrome or Ehlers-Danlos syndrome (EDS), although this is rare.

How is pectus excavatum diagnosed?

Pectus excavatum is usually diagnosed during a physical examination. X-rays of the chest can help your child’s doctor confirm the diagnosis.

At Boston Children’s Hospital, we also use a white light scanner — a type of three-dimensional (3D) camera — to help measure your child’s chest wall depression and monitor their response to treatment over time.

Other recommended tests might include:

• echocardiogram (also known as cardiac ultrasound)
• pulmonary function test (PFT)
• cardiopulmonary exercise test (CPET)

How is pectus excavatum treated?

If your child has a mild case of pectus excavatum, they may not need treatment. A shallow indentation probably will not affect heart or lung function or the appearance of their chest. If pectus excavatum is causing your child physical or social problems, there are treatment options. At Boston Children’s, we typically start with non-surgical treatment and only recommend surgery if that is the only option to correct the shape of the chest.

Non-surgical treatment: Vacuum bell therapy

Vacuum bell therapy uses a device worn on the outside of the body and creates suction to lift the breastbone forward over time. It typically works best for children who are younger, have mild pectus excavatum, and who have flexible chest walls. Your child will need to wear the device for a total of four hours every day. The therapy usually takes at least two years, but that may depend on your child’s growth.

Surgical treatment

If your child’s pectus excavatum is more severe or does not improve with vacuum bell therapy, there are two surgical options to correct the shape of the chest.

Minimally invasive repair

The Nuss procedure is minimally invasive surgery in which a surgeon makes small cuts on each side of the chest and inserts a curved bar under the breastbone. The bar, which has been shaped to the contours of your child’s chest, presses the breastbone forward. Sometimes more than one bar is needed. The bar usually remains in the chest for three years while the breastbone grows around it. Removing the bar is a simple procedure.

Open repair

The Ravitch procedure, also known as the Welch procedure, is an open surgery in which the surgeon makes a cut across the front of the chest and removes cartilage that is causing the breastbone to grow inward. The surgeon then reshapes the breastbone and may place a metal bar to hold it in place while it heals. The bar usually remains in place for six to 12 months while new cartilage grows.

What are the benefits of treating pectus excavatum?

Most children with pectus excavatum don’t need any treatment at all. In severe cases, repairing the chest wall may help the function of the heart and lungs. But in most cases, the biggest benefits of treatment are psychological. If your child is upset by their chest’s appearance, treatment can make a big difference in their self-confidence.

How we care for pectus excavatum

The Pectus and Chest Wall Treatment Program at Boston Children's Hospital evaluates and treats infants, children, and young adults using state-of-the-art operative and non-operative methods to improve the quality of life for each child entrusted to our care.

In many cases, we recommend close observation to determine if a patient needs any treatment at all. If pectus excavatum causes physical or social problems, we initiate a treatment plan designed for your child’s specific anatomy and preferences. If your child is young and able to wear a vacuum bell daily, we will fit them to the correct vacuum bell device and monitor their response to treatment over time. If your child has severe pectus excavatum, is older, or does not improve with vacuum bell therapy, we may offer surgery.

When pectus excavatum requires surgery, our surgeons prefer to operate during a child’s teen years. We use advanced techniques such as cryoablation for pain management, which has been proven to reduce the length of hospital stay, decrease the need for pain medication, and improve recovery times.

As part of Boston Children’s Hospital, we offer patients access to the extensive resources of the nation’s leading pediatric hospital. If one of our patients also has scoliosis, we work closely with Boston Children’s Spine Division to coordinate treatment for both conditions.

When a patient is at risk of a connective tissue disorder such as Marfan syndrome or Ehlers-Danlos syndrome, we will refer them to the Center for Cardiovascular Genetics for additional diagnostic testing. If a patient has Poland syndrome (part of the chest and shoulder has not developed fully), we work closely with Boston Children’s Department of Plastic and Oral Surgery to plan and carry out their treatment.