Pectus excavatum (funnel chest): causes, treatment and surgery

Pectus excavatum means "hollowed chest". The Scottish National Chest Wall Service says it is a condition where the front of the chest is sunken, and the Alder Hey leaflet explains that the breastbone (sternum) is sunken because of abnormal growth of the cartilage that joins the ribs to the breastbone.

The Alder Hey leaflet says there may be a genetic link, as it seems to run in families, that it can appear as a feature of Marfan syndrome or alongside scoliosis, and that it is four times as common in boys as in girls. The Scottish service says that on rare occasions there may be a genetic explanation such as Marfan syndrome.

The main sign is the appearance of the chest: a visible dip or hollow in the breastbone area. The Alder Hey leaflet says it can be noticeable soon after birth, although it is often in the teenage years that the shape becomes more of a problem as children become more self-conscious.

The Scottish service says that in mild cases there is no obvious effect apart from the appearance of the chest, whereas in more severe cases it may affect heart and lung function. The Alder Hey leaflet says that appearance is the main problem, although in rare cases it can affect how the heart and lungs work.

Pre-surgery assessment at one hospital includes a CT scan, lung function tests, an electrocardiogram and an ultrasound of the heart. The leaflet says the results are usually normal, unless the child has symptoms such as shortness of breath on exercise.

It is caused by abnormal growth of the cartilage ribs that attach to the breastbone. The Scottish service explains that it can occur at or soon after birth, but that in most cases it occurs following a growth spurt, typically as young people leave primary school and enter secondary school at 11 to 14 years.

The Scottish service estimates that it occurs in fewer than 10 people per 1,000 in the UK and that boys are affected 4 times as often as girls. The Alder Hey leaflet gives a figure of about 1 in 1000 children. The two figures reflect different estimates, but both describe a minority of children, with boys affected more often.

The Scottish service says diagnosis is made by looking at the chest. Other tests may be necessary to look at the heart and lungs, especially if treatment is being considered. If you or your child notice a sunken chest, a GP can examine it and refer to a paediatric or chest wall service if needed.

The Scottish service describes two main routes. Mild cases may need no corrective treatment, with physiotherapy assessment and advice aimed at posture, core strength and breathing, and with exercise to maintain flexibility, strength and good posture. For some children and young people a vacuum bell device is offered. Surgery is only required for more complex cases, after a full assessment and ensuring it is the right option for the young person.

The Alder Hey leaflet describes the Nuss procedure as a newer, less invasive operation that does not require the chest to be opened. A curved steel bar is inserted through incisions on either side of the chest so that it lies behind the breastbone, then turned so the curve faces forwards, pushing the breastbone out. Sometimes two bars are used. The operation lasts about 1.5 to 2 hours and the bar needs to stay in place for at least 2 years. The leaflet says it is usually carried out in children and young adults and is also known as MIRPE.

The leaflet says surgery can be performed at any age but is recommended in mid to late childhood, partly so the young person is mature enough to follow the post-operative instructions. It describes the procedure as cosmetic, saying it does not offer health benefits in itself, so the decision is about whether the improvement in appearance is worth the risks, and notes that it cannot say how much a given chest can be improved.

Possible risks listed include injury to the lungs, heart, liver or a chest artery, fluid around the heart or lungs, the bar moving, air or blood in the chest cavity, keloid scarring, wound infection, pain and metal allergy. The leaflet says patients can usually leave hospital 4 to 5 days after surgery, most children return to school within two weeks with exercise restrictions, and the bar is later removed as a day case. The Scottish service quotes a hospital stay of 5 to 7 days.

After surgery both services give detailed precautions because the bar can move. The Scottish service lists avoiding forward or side bending, twisting, rolling, lying on your side and raising the arms above shoulder height for the first 3 weeks, along with no lifting or pushing through the arms.

The Alder Hey leaflet lists taking it easy for the first four to six weeks, sleeping on your back for the first four weeks, no lifting or pushing up from a chair using the arms for 3 months, swimming and jogging from 3 months, no contact sports for six months and no driving for three months. It adds that CPR and defibrillation can be performed if needed, and that MRI of the chest is not advised while the bar is in place, so people should tell staff about the bar.

The Alder Hey leaflet lists the signs for which a child who has had surgery should attend A&E or call 999: a temperature above 38 degrees, redness, swelling, drainage or bleeding from the incisions, worsening chest pain, pain not controlled by medicines, problems with breathing, a cough that does not go away, an injury to the chest that may have moved the bar, and sudden chest pain or breathlessness.

Outside surgery, see a GP if a sunken chest comes with breathlessness, tiredness on exercise or chest pain, so the heart and lungs can be checked.

On the NHS, a GP can refer a child or young person with a significant chest wall deformity to a paediatric or specialist chest wall service, where physiotherapy, a vacuum bell and surgery may be considered after assessment. The Scottish National Chest Wall Service accepts referrals for children and adolescents up to age 16.

Private surgical services may also offer the Nuss procedure. Because the Alder Hey leaflet describes the operation as cosmetic rather than treating a health problem, ask your GP or specialist how decisions about surgery are made and what assessment is required first.