Pectus excavatum, also known as sunken chest or funnel chest, is the most frequent congenital anomaly of the chest wall, occurring in 1 in 400 births, and is found in 2.6 percent of children aged 7–14. It occurs when an abnormal growth of cartilage within the chest wall pushes the sternum, or breastbone, and ribs inward creating a caved-in or sunken appearance. If the ribs grow faster than the expansion of the heart and lungs, then the sternum can be pushed inward instead.
While it usually occurs as a stand-alone condition, up to 20 percent of patients may have other skeletal conditions, such as scoliosis.
The condition seems to be more common in boys than girls. It often doesn’t fully manifest until adolescence during rapid bone growth and if severe, can be treated with surgery at that time. The cause is not known, but there is sometimes a tendency to run in families.
It may cause children to sometimes feel shortness of breath or experience exercise intolerance or palpitations, interfering with heart and lung function. Regardless of the severity, as the child reaches the pre-teen or adolescent years, the caved-in or hollow appearance may make them self-conscious and can cause anxiety.
Because of the visual nature of this condition, pectus excavatum can usually be initially diagnosed by physical examination of the chest wall. Depending on the symptoms and clinical findings, the medical team may request a series of tests including echocardiogram, pulmonary function test or CT scan.
Although the initial care may include monitoring a patient’s growth and chest-specific physical therapy, surgical correction may be provided. The team will look at conservative treatment options, as well as surgery. Some other options may include physical therapy evaluation and treatment, as well as an annual follow-up in the Chest Wall Deformities Clinic.
If your child is an appropriate candidate for surgery, it is likely they will have either the Ravitch procedure or the minimally invasive Nuss procedure.
With the Ravitch procedure, the surgeon will make an incision to remove abnormal cartilage and place the sternum in the appropriate position. The surgeon may also insert a steel bar to support and elevate this area as it heals. When used, the bar is removed approximately one year later as an outpatient procedure. The Ravitch surgery is especially well suited for patients who do not wish to have a bar in place for more than one year and those with highly asymmetric chest wall deformities or problematic lower rib flaring.
The Nuss procedure is a minimally invasive surgery. Incision sites are made on both sides of the chest wall and corrective, custom-fitted steel bar(s) are inserted under the sternum and secured in place. Typically these bar(s) remain in place for two to three years. The Nuss procedure, because of the smaller incisions, results in less obvious scarring.
The decision about which surgery is best for your child is based on a number of factors that are specific to each patient.
If you decide to have surgery, there are exercises you can do both before and after, which will help with recovery.
Beforehand, exercises that will strengthen your chest muscles will help increase strength and make your muscles more balanced. It will also help your chest wall adjust more easily after surgery.
After surgery, activities that begin to get you moving are important.
For both the Ravitch procedure and the Nuss procedure, the average hospital stay is four to seven days.
The surgeries for pectus excavatum and pectus carinatum are both done under general anesthesia. Sometimes prior to surgery, an anesthesiologist may insert an epidural catheter into the back while your child is asleep. An epidural is a small tube that will allow your child to receive pain medication after surgery.
The teams at Lurie Children’s care very much about the comfort of patients after surgery and do everything possible to minimize any discomfort that can occur. After your child is awake and is in the recovery room, the recovery room nurse and the anesthesiologist work together to ensure that the child is as comfortable as possible.
Your child may receive a combination of Intravenous (IV) and oral pain medications after surgery. This may include the epidural or patient-controlled analgesia (PCA) pump.
Once your child is ready, the IV pain medications are stopped and your child will be transitioned to a combination of oral pain medications in preparation for discharge home. Most children will require two to three weeks of oral pain medications after they are discharged from the hospital.
Below are two additional resources on pain management:
It is important to take very good care of the surgical site until it is fully healed.
Access and download instructions on pediatric surgery postoperative wound care:
In terms of resuming normal activity, patients are generally advised to abstain from heavy physical exertion for about 6 weeks. This also means, no backpacks on the shoulder for three months so the area is not stressed.
They can return to very light aerobic activity, including walking and doing breathing exercises, six weeks after surgery. No running, working out, sit-ups or biking to protect the area.
After six weeks, patients can begin stronger cardiovascular conditioning such as running, swimming, biking, pilates or yoga.
After the initial six-week period of recovery, patients can slowly begin to engage in more intense sports, such as basketball or hockey. The operation is intended not to limit physical activity, but any reasonable precautions should be taken so as to avoid receiving a forcible blow to the chest, as that could cause the bar to shift.
It is important that patients see their surgeon regularly until the bar is removed, so they can ensure the process is healing correctly.
For the minimally invasive Nuss procedure that is about 2–3 years. For the Ravitch procedure, it is approximately 1 year.
Routine post-surgical follow-up with your pediatric surgeon and team is important and should be done at regular intervals for up to two years post-surgery. Check with your surgeon on the exact interval timing. Please call the Division of Pediatric Surgery directly to make your appointments: 312.227.4210. These appointments can be made for either our Northbrook or Lurie Children’s downtown locations:
Outpatient Center in Northbrook
1131 Techny Road
Northbrook, IL 60062
Ann and Robert H. Lurie Children’s Hospital of Chicago
225 E. Chicago Ave.
Chicago, IL 60611
Between appointments, seek medical attention if you have any of the following symptoms: chest pain, shortness of breath, persistent cough, fevers greater than 101.5F, pain unrelieved by oral medications, constipation or other concerns.