Structural abnormalities of the chest – pigeon chest and funnel chest

What is the structure of the normal chest?

The chest is made up of 12 pairs of ribs that are attached to the vertebral column from the back, and to the sternum, a cartilaginous tissue, in the front.
An asymmetrical growth of these cartilages, particularly the middle and lower ones, can cause the sternum to sink deeper into the chest or be pushed more to the front.

What is funnel chest?

See the image attached.
When the sternum is sunken into the chest, the chest is referred to as funnel chest, or pectus excavatum.
The prevalence of this abnormality is 1:1000 live births, it is more common in boys and in about 40% of the cases it can be familial. This abnormality is the most common one among chest abnormalities. Sometimes it is symmetric but in most cases there is a sinking of the ribs and of the sternum and an asymmetric manner.
This process of sinking manifests mainly during growth spurts in adolescence.

What is pigeon chest (a bulge in the chest)?

See the image attached.
When there is a bulge in the chest it is referred to as pigeon chest or pectus carinatum. This abnormality can be found in 1:1500 live births.

What is the problem with pigeon chests or funnel chests?

Children with pigeon chest or funnel chest tend to have negative body image. It is common to see them with sloped shoulders, as they try to conceal their structural abnormality. They tend to avoid joining social activities where they would have to expose their upper bodies. They are often reserved and avoid social contact.
In addition to their problems with body image, there has been increasing evidence about the long-term effect of funnel chest on cardiac function. The medical literature has demonstrated that adult patients who undergo surgical correction of the structural abnormality have improved cardiac function. Therefore, there is no doubt that it is not only a cosmetic disorder.

What are the investigations that need to be done when one presents with a structural abnormality of the chest?

The diagnosis includes a cardiac and respiratory assessment, to examine the effects of the abnormality on the heart and the respiratory tract. Depending on the symptoms, cardiopulmonary exercise testing can also be performed, to examine the heart-lung capacity during stress tests and a cardiac MRI to check the function of the heart with the help of magnetic resonance imaging. The need for these tests is individual to the patient, and will be determined by the specialist.

What is the treatment for funnel chest?

The treatment for funnel chest is surgical and can be divided into two different techniques, depending on the shape of the chest:
1. The open technique known as the Ravitch Procedure – performed with an incision in the front of the chest and includes removal of abnormal cartilage on both sides of the sternum. In addition, the angle of the sternum is corrected and it is placed in the normal position.
2. The minimally invasive technique is known as the Nuss Procedure – it is performed through two small incisions on both sides of the chest and includes lifting the sternum with the help of a metal supporter, without removal of any cartilage or breaking of the sternum. This supporter remains in the chest for about 3 years and is then pulled out through an additional minimally invasive procedure. The ideal age for this surgery is 14-16 years.
This technique (Nuss) is preferred over the other because from a cosmetic perspective, the results are better, not necessarily in the sense of the correction of the abnormality, but more so because it does not leave a long scar in the front of the chest. Fortunately, most of the surgical corrections in the past decade have been done using the Nuss procedure.

What is the treatment for pigeon chest?

A large proportion of these cases can be treated conservatively with the use of an external pressure brace customized for the patient. The cases that cannot be treated conservatively undergo a surgery that is based on the Ravitch procedure described above.
For teenagers, it seems more appealing to get a surgery done that will “fix” the abnormality immediately, compared to having to wear a brace underneath their clothes for a long period of time (2 years). Nonetheless, the conservative treatment (without surgery) can be very successful in symmetric cases of the lower sternum, and does not medically justify the need for a surgery. That is why in recent years there has been a growing number of companies that market different models of treatment braces to manage this condition, which is mostly done during adolescence.

Is it important to treat structural abnormalities of the chest?

Despite what most people think, structural abnormalities of the chest are not only cosmetic and can have a long-term effect on the heart as well as a patient’s mental/social state and therefore the importance of management of these abnormalities is not only cosmetic.

In summary, structural abnormalities of the chest, funnel chest and pigeon chest, a super important topic for children who suffer from this condition and therefore it is worth consulting with experienced specialists, so that your child can receive the best treatment available.