What is the management and treatment of Pectus excavatum (funnel chest)?

Management and Treatment of Pectus Excavatum (Funnel Chest)

Pectus excavatum should be evaluated for both physiological impact and psychological effects, with surgical intervention recommended for moderate to severe cases causing cardiopulmonary compromise or significant psychological distress. 1, 2

Clinical Evaluation

• Pectus excavatum is a congenital deformity characterized by a depression of the sternum and costal cartilages, with the apex at the xiphoid process 3
• The condition may occur as an isolated abnormality or in association with connective tissue disorders such as Marfan syndrome, where it is considered part of the systemic features scoring system 4
• Pectus excavatum can occur as an autosomal dominant trait in some families, suggesting a genetic component 4

Assessment Parameters

• Cardiopulmonary function evaluation:

  • Echocardiography to assess cardiac compression and displacement 2
  • Pulmonary function tests to identify decreased lung volumes or evidence of lower airway obstruction 2
  • Exercise testing to evaluate cardiovascular limitations during exertion 2

• Imaging studies:

  • Chest X-ray to document the severity and configuration of the deformity 1
  • CT scan to calculate the Haller index (ratio of transverse diameter to anteroposterior diameter) 3

• Psychological assessment:

  • Evaluation of body image concerns and psychological impact, which often exceeds physical effects 2

Treatment Approach

Non-surgical Management

• Observation for mild cases without physiological or psychological impact 1
• Physical therapy for minor deformities to improve posture and chest expansion 1
• Vacuum bell therapy as a non-surgical option for selected patients 3

Surgical Intervention Indications

• Moderate to severe deformity with cardiopulmonary compromise 5
• Significant psychological distress affecting quality of life 2
• Progressive worsening of the deformity 1

Surgical Options

• Ravitch procedure (open technique):

  • Involves extensive resection of costal cartilages and sternal repositioning 1
  • Stabilization with metal strut has shown excellent long-term results 1

• Nuss procedure (minimally invasive):

  • Placement of a curved metal bar behind the sternum without cartilage resection 3
  • Less invasive with shorter operative time but requires bar removal after 2-4 years 3

Special Considerations

Timing of Surgery

• Early surgical intervention in infancy may be preferable as the procedure is simpler and less extensive than when performed in adulthood 5
• For patients beyond infancy, cardiorespiratory studies help determine the necessity of surgery 5

Coexisting Cardiac Conditions

• In patients with concomitant congenital heart disease (rare, occurring in approximately 0.17% of cases), special consideration is needed for the timing of repairs 6
• For patients requiring extracardiac conduits for cardiac repair, pectus excavatum should be corrected first to prevent compression of the conduit 6
• Simultaneous repair of cardiac defects and pectus excavatum should be avoided due to potential major complications 6
• Pectus repair can be safely performed after cardiac surgery through a median sternotomy 6

Follow-up Care

• Regular monitoring of cardiopulmonary function post-repair 2
• Assessment of cosmetic outcomes and patient satisfaction 1
• Psychological support as needed 2

Pitfalls and Caveats

• Objective photographic documentation is essential for surgical planning and outcome assessment 1
• Different types of deformities (symmetrical, asymmetrical, localized, extensive) require tailored surgical approaches 1
• Patients with Marfan syndrome or other connective tissue disorders require additional cardiovascular monitoring regardless of pectus repair 4
• The psychological impact of the deformity should not be underestimated when considering treatment options 2