What is pectus? Q&A with Lurie Children’s chest wall experts
Children with chest wall anomalies such as pectus excavatum (sunken chest) and pectus carinatum (pigeon chest) can find confidence in the care they receive at Lurie Children’s with the region’s most experienced Chest Wall Deformities team.
Chest wall conditions can cause a young patient to feel short of breath or have trouble when exercising. Patients with a sunken chest may have heart palpitations and dislike the hollow and caved-in appearance of their chest. Meanwhile, patients with pigeon chest, when the breastbone rises outward, may have chest pain as they grow.
Seeing a specialist early on in a child’s life, by around age 10 years, is key for the most effective treatment and best outcomes.
Lurie Children’s Chest Wall Deformities Program includes specialists Fizan Abdullah, MD, PhD, Head of the Division of Pediatric Surgery, Marleta Reynolds, MD, Surgeon-in-Chief, Department of Surgery; Seth D. Goldstein, MD, MPhil; Suzanne Kujawa, MS, APRN, CPNP; Laurie Sands, MS, APRN, CPNP PC/AC; and Irma Ortiz, RN. These providers all have special training in diagnosing and treating chest wall conditions.
Read more below, where the team answers the most common questions about chest wall anomalies.
What is a chest wall deformity? How common are they?
Suzanne Kujawa, MS, APRN, CPNP: A chest wall deformity is an abnormality in the development of the chest wall. The two most prominent conditions are pectus excavatum (sunken chest, when the breastbone sinks into the chest) and pectus carinatum (pigeon chest, when the breastbone is raised up, or out).
It can have a genetic component and is sometimes seen in families. Pectus excavatum can affect 1 in 300 to 400 individuals and pectus carinatum can affect 1 in 1,500 individuals. Both are more common in males.
At what age might the sunken or protruding chest be noticeable?
Fizan Abdullah, MD, PhD: Patients can be diagnosed with pectus at birth, after a chest wall surgery or during their adolescent period of growth. We most commonly see pectus in growing adolescents. Many of our patients seek care with us when they are in elementary school, or at the time they receive the diagnosis of a chest wall deformity. Your primary care provider can initially diagnose your chest wall deformity. There are many variations of chest wall deformities and we recommend a consultation with a specialty clinic, like the Chest Wall Deformities Program at Lurie Children’s, to make sure you have the right diagnosis and are aware of the treatment tools available to your child.
How is pectus treated?
Laurie Sands, MS, APRN, CPNP PC/AC: Treatment for chest wall anomalies depends primarily on the type and severity of the chest wall anomaly. Pectus excavatum can place pressure on the surrounding structures of the chest such as the heart and lungs. This may require surgical interventionto allow more space for the heart and lungs to function. Once a patient has been evaluated by the team, further testing may be needed to help determine if surgery would be recommended. A CT scan will provide a Haller Index measurement, which provides an indicator of the severity of the pectus curve. Your care team will discuss these results with you and provide a recommendation on your treatment based on your complete clinical picture.
An echocardiogram is needed for all patients with chest wall anomalies to evaluate for known associated heart conditions but may be helpful in evaluating if there is compression to the heart from the pectus deformity in determining if surgical intervention would be beneficial to the patient.
Some patients may not need surgery and benefit from a physical therapy program to optimize the development of the chest wall with exercises focused on posture and breathing. These patients should continue to be monitored annually by a specialist.
Pectus carinatum, or pigeon chest, can be corrected via use of a custom external compression device worn overnight every night. Bracing is typically a highly successful strategy to help patients reduce their pectus carinatum and provide them with a more symmetric appearing chest. If bracing is not an option, there is also a surgical procedure that is sometimes suggested for patients who are unable to successfully brace. That is called the Ravitch procedure, and our surgeons at Lurie Children’s are experienced in identifying patients who may ultimately benefit from the Ravitch.
Seth Goldstein, MD, MPhil: For pectus excavatum, your surgical team may discuss the minimally invasive repair, often called a Nuss procedure (named after the procedure’s founder, Dr. Donald Nuss), with your family. The Nuss procedure is performed over many hours in the operating room. The child is asleep and does not feel or remember anything from that time. First, the surgeon performs a freezing of the nerves that run along the ribs; this decreases the discomfort felt afterwards. Then the surgeon passes a curved metal bar across the chest, keeping the heart and lungs out of harm’s way.
Dr. Abdullah: This metal bar helps to create more volume in the chest for the heart and lungs to function. The change in the chest configuration is immediate after the surgery. The bar is secured into place for stability and is removed between 2 and 3 years later.
You can watch a video of what this procedure looks like here.
If the Nuss procedure is needed, what is recovery like?
Suzanne Kujawa: We have many care guidelines in place to modulate the pain our patients experience. During the surgery, cryoablation is utilized to freeze the nerves of the chest wall internally. This helps reduce pain after the surgery. Cryoablation acts as a "kink in a hose" to stop the chest wall nerves from firing pain signals past the point of freezing. Over time, the nerves regenerate and resume normal function.
The patient may also take prescribed narcotics and over the counter medications on a schedule until they are safely weaned off all medications. Patients generally need narcotics for a few days after surgery. Patients can be safely discharged from the hospital following surgery when they are moving around independently, their pain is controlled on their oral medications and they are eating well.
Dr. Goldstein: Most teenagers spend 1-2 nights in the hospital recovering afterwards and have a continued recovery at home with gradual resumption of physical activity over 10-12 weeks.
Does treatment differ for males and females?
Laurie Sands: Treatment for pectus is the same for both males and females.
For our female patients, we do make considerations to begin bracing at an earlier age, prior to puberty and the development of breast tissue as this can make bracing more challenging for female patients due to discomfort.
How do the lives of those treated for pectus improve following treatment and/or surgery?
Dr. Goldstein: After the Nuss procedure for pectus excavatum, many children feel that they can breathe more easily and get less short of breath with physical activity. When the implanted bar is removed during an outpatient surgery after two years, the chest will remain flat and no further therapies are needed.
Suzanne Kujawa: Carinatum (pigeon chest) patients are empowered to improve their chest walls and are proud of their dedication to the process of improving their chest wall. Patients who have undergone the Nuss procedure often report that they are very happy with the appearance of their chest walls and are less short of breath than before surgery.
Why is Lurie Children’s the best place for pectus treatment?
Dr. Abdullah: We have a multidisciplinary team of experts focused on this condition. Few Chest Wall Deformity Programs in the nation see more patients or do more surgeries with excellent outcomes.
When parents come to Lurie Children’s for chest wall deformity treatment, they can be assured that they are being taken care of by the most experienced team in the region.
Laurie Sands: Lurie Children’s provides state-of-the-art care for all our chest wall patients. This includes white-light scanning, which captures a 3D, computerized model of the patient's chest wall. We can visually and mathematically track changes in the patient's chest wall over time and this can further magnify the impact the Nuss procedure can have on a patient's thoracic volume.
We anticipate the needs of our patients and have a guided recovery plan related to activity that our experts in physical therapy have assisted us with developing so that patients who have undergone the Nuss repair can return to activities they enjoy as soon as possible. We provide personal, individualized care to each patient. The Chest Wall Deformities program is more than a program, we are family.