Understanding Pectus Excavatum in 13 - Year - Olds

Pectus excavatum is a congenital chest wall deformity that occurs when the cartilage connecting the ribs to the breastbone (sternum) grows abnormally, causing the sternum to be caved in. This gives the chest a "sunken in" or "funnel chest" appearance. It is more common in boys than girls and often becomes more noticeable during puberty, which can be around the age of 13. In some cases, pectus excavatum may be barely noticeable, while in severe cases, it can cause significant problems with the heart and lungs. The disorder affects approximately one in 400 births, according to research from PMC.

Signs and Symptoms

- **Visible Appearance**: A 13 - year - old with pectus excavatum may have a clearly sunken chest. The ribs may stick out on one side, or there could be rib flare where the lower ribs jut out, making the child look like they have a potbelly. - **Respiratory Issues**: Severe cases can put pressure on the lungs, leading to shortness of breath, especially during exercise. The child may find it difficult to keep up with their peers during physical activities like running or playing sports. - **Cardiac Problems**: The heart may also be affected, as it can be pushed from the midline and rotated to the left side of the chest. This can potentially impact its ability to pump blood efficiently, causing symptoms such as a rapid heartbeat, heart palpitations, or dizziness when standing up. - **Chest Pain**: Some kids may experience chest pain that comes and goes, tiredness, or fatigue.

Causes

Doctors don't know exactly what causes pectus excavatum. However, in some cases, it runs in families, suggesting a genetic component. Kids with pectus excavatum may also have other related health conditions such as scoliosis, Marfan syndrome, Poland syndrome, or Ehlers - Danlos syndrome. Genetic tests can be used to check for these associated conditions.

Evaluating Pectus Excavatum in 13 - Year - Olds

The evaluation of pectus excavatum in a 13 - year - old is crucial to determine the severity of the condition and whether treatment is necessary.

Physical Examination

Doctors start by conducting a physical exam of the child's chest. They look for the characteristic sunken appearance, rib flare, and any other visible signs of the deformity. They also check for signs of heart or lung problems during the physical examination.

Imaging Tests

- **Chest X - ray**: This can provide a basic view of the chest structure. It measures the width of the chest inside the rib cage and the depth of the chest from the back of the sternum to the vertebrae of the spine. - **CT Scan**: A CT scan of the chest is essential as it provides the Haller index. The Haller index is the ratio between the transverse chest diameter (measurement from one side of the rib cage to the other) and the anteroposterior diameter (measurement from the breastbone to the spinal cord) of the chest. A normal chest ratio is approximately 2.5 cm, and an index over 3.2 cm is often defined as severe and eligible for surgical correction, according to the Children's Hospital of Philadelphia. - **MRI**: In some cases, an MRI may be ordered to get a more detailed look at the heart and lungs and to assess any potential compression or displacement.

Cardiac and Pulmonary Function Tests

- **Echocardiogram**: This test is used to check how well the heart is functioning. It can detect if the pectus deformity is compressing the heart and affecting its ability to pump blood. - **Pulmonary Function Tests (PFT)**: PFTs measure the amount of air a child can get into and out of their lungs. They help determine if the lungs are being restricted due to the chest deformity.

Treatment Options for Pectus Excavatum in 13 - Year - Olds

The treatment of pectus excavatum in a 13 - year - old depends on the severity of the defect and the child's symptoms.

Non - Surgical Options

- **Vacuum Bell Device**: A vacuum bell can be used at home. It is placed on the child's chest and connected to a pump that sucks the air out, creating a vacuum that pulls the chest forward. Kids wear it each day for several hours, and it can take 3 - 6 months to see any changes. This device tends to work better on younger children but can be used for all ages. - **Physical Therapy and Exercises**: Doctors may also suggest physical therapy and specific exercises. These can help strengthen the chest muscles and improve posture, which may have a positive impact on the appearance and function of the chest.

Surgical Options

- **The Nuss Procedure**: This is a minimally invasive technique for surgical repair. The surgeon makes two small incisions, one on each side of the chest. A small video camera called a thoracoscope is placed through one of the incisions to allow the surgeon to view inside the chest. A curved steel bar, shaped to fit the child, is inserted through the incisions and placed under the breastbone to lift it. The bar is left in place for at least 2 years to help the breastbone grow properly. It is the most common surgical procedure for pectus excavatum. - **The Ravitch Procedure**: This is an open surgery. The surgeon makes an incision across the front part of the chest, removes the deformed cartilage, and leaves the rib lining in place to allow the cartilage to grow back correctly. A cut is made in the breastbone, which is moved to the correct location, and a metal strut may be used to hold it in place until it heals. The struts are removed in 6 - 12 months. This procedure is typically used for patients 13 to 22 years old and may be a better option if the child has twisting (torsion) of the chest.

Treatment Option	Advantages	Disadvantages
Vacuum Bell Device	Non - invasive, can be used at home	Requires long - term use, may take months to see results
Nuss Procedure	Minimally invasive, smaller incisions, reduced scarring	Bar needs to be in place for at least 2 years, potential complications
Ravitch Procedure	Can correct more complex deformities, may be better for chest torsion	Open surgery, longer recovery time, more invasive

Pectus Excavatum Surgery in New York City: Ranking Factors

When considering the ranking for pectus excavatum surgery on a 13 - year - old in New York City, several factors come into play.

Surgeon Experience

Surgeons with more experience in performing pectus excavatum surgeries are likely to have better outcomes. They are more familiar with the nuances of the procedures and can handle any potential complications that may arise during surgery. In New York City, there are many highly skilled pediatric surgeons who specialize in chest wall deformities. Surgeons at well - known hospitals like Mount Sinai and the Children's Hospital of Philadelphia (CHOP) have extensive experience in treating pectus excavatum.

Hospital Facilities

Hospitals with state - of - the - art facilities and advanced technology are better equipped to perform pectus excavatum surgeries. For example, a hospital with high - quality imaging equipment can provide more accurate pre - operative evaluations, which is crucial for successful surgery. Additionally, hospitals with dedicated pediatric intensive care units (PICUs) can provide better post - operative care for the child.

Patient Outcomes

The success rate of the surgeries performed at a particular hospital or by a specific surgeon is an important ranking factor. This includes not only the cosmetic improvement of the chest but also the resolution of any heart or lung problems. Follow - up data on patients' recovery, return to normal activities, and long - term results are also considered.

Patient and Family Satisfaction

The experiences of patients and their families are also taken into account. This includes factors such as the quality of communication with the medical staff, the level of support provided during the pre - operative and post - operative periods, and the overall comfort of the hospital environment.

The Ravitch Procedure in Detail

The Ravitch procedure is a well - known surgical option for treating pectus excavatum, especially for patients in the 13 - 22 - year - old age group.

Procedure Steps

- **Incision**: The surgeon makes an incision across the chest to access the affected area. - **Sternum Repair**: The surgeon repairs or reshapes the sternum to correct the deformity. - **Bar Placement**: In some cases, one or more bars are placed to keep the sternum in its new position. These bars are typically removed after about 6 months. - **Fluid Drainage**: One or more drains are placed under the skin to drain fluid from the surgery site. A chest tube may also be placed to prevent the lung from collapsing. - **Incision Closure**: Finally, the surgeon closes the incision.

Post - Procedure Care

After the Ravitch procedure, the child needs pain medicine and rest. They should stay home from school until they no longer need to take prescription pain medicine. Breathing and other exercises as recommended by the surgeon can help with recovery. For a few months, the child should: - Avoid gym class at school - Not carry a backpack or other heavy bag - Avoid strenuous activity, including running - Not drive - Ride in the back seat of cars to avoid possible trauma from an airbag - Not play sports that could cause injury to the chest (such as football, soccer, and baseball) It may take 6 months or more for the child to safely return to all the activities they did before the surgery.

Risks of the Ravitch Procedure

As with any surgery, there are risks associated with the Ravitch procedure. These include: - **General Surgical Risks**: Bleeding, infection, and problems with anesthesia. - **Procedure - Specific Risks**: Pain that can last a month or more, fluid collection under the skin at the surgery site, fluid around the lung or a collapsed lung, bars that move out of place, damage to the heart or lungs during surgery, and the recurrence of pectus excavatum.

The Nuss Procedure in Detail

The Nuss procedure is a minimally invasive alternative for treating pectus excavatum, commonly used on adolescent patients.

Procedure Steps

- **Incision**: The surgeon makes two small incisions, one on each side of the chest. - **Camera Insertion**: A thoracoscope is inserted through one of the incisions to allow the surgeon to view inside the chest. - **Bar Placement**: A curved steel bar is inserted through the incisions and placed under the breastbone to lift it. The bar is fixed to the ribs on each side and stays in place for at least 2 years. - **Closure**: The thoracoscope is removed, and the incisions are closed.

Post - Procedure Care

After the Nuss procedure, the child usually stays in the hospital for a few days to recover. Pain management is important, and the child may receive strong pain medicine in the vein or through an epidural catheter initially, followed by oral pain medicine. The child may have tubes in the chest to drain extra fluid, which are removed when they stop draining. The day after surgery, the child is encouraged to sit up, take deep breaths, and get out of bed and walk to aid in healing.

Risks of the Nuss Procedure

- **General Risks**: Similar to other surgeries, there are risks of bleeding, infection, and reactions to anesthesia. - **Procedure - Specific Risks**: Pneumothorax (collapsed lung), pleural effusion (fluid around the lung), displacement of the bar, and recurrence of pectus excavatum.

Preparing for Pectus Excavatum Surgery

Before a 13 - year - old undergoes pectus excavatum surgery, several steps need to be taken.

Medical Exams and Tests

- **Complete Medical Exam**: The child will have a thorough medical examination to assess their overall health. - **Cardiac and Pulmonary Tests**: An electrocardiogram (ECG), echocardiogram, and pulmonary function tests may be ordered to evaluate the heart and lung function. - **Imaging Tests**: A CT scan or MRI of the chest is usually done to determine the severity of the deformity and plan the surgery.

Medication Management

About 7 days before surgery, the child may be asked to stop taking aspirin, ibuprofen, naproxen, warfarin, and other blood - thinning drugs. The surgeon will also let the parents know which drugs the child should still take on the day of surgery.

Pre - operative Instructions

- **Diet Restrictions**: The child will likely be asked not to drink or eat anything after midnight the night before surgery. They may be given a small sip of water to take any necessary medications. - **Comfort Items**: Parents can bring a favorite stuffed animal or blanket for the child to hold before and after the surgery to help them stay calm.

Recovery and Follow - Up After Pectus Excavatum Surgery

The recovery process after pectus excavatum surgery is crucial for the child's long - term well - being.

Hospital Stay

The child will usually stay in the hospital for 3 - 7 days, depending on the type of surgery and how well the recovery is going. During this time, pain management is a priority, and the medical staff will closely monitor the child's vital signs, drainage tubes, and overall condition.

Home Care

- **Pain Medication**: The child will be given a prescription for pain medicine to take at home. Parents should follow the dosage instructions carefully. - **Activity Restrictions**: The child will have limitations on their activities for several months. They should avoid strenuous activities, bending, twisting, and contact sports. They may also need to avoid carrying heavy objects, such as backpacks. - **Wound Care**: The parents should keep the surgical incisions clean and dry and follow the doctor's instructions on dressing changes.

Follow - Up Visits

The child will need to have follow - up visits with the surgeon. These visits are important to monitor the healing process, remove any remaining bars or tubes, and assess the long - term results of the surgery. During these visits, the surgeon may also order additional tests, such as chest X - rays or CT scans, to evaluate the progress.

Conclusion

Pectus excavatum in a 13 - year - old can have a significant impact on the child's physical and emotional well - being. The evaluation and treatment of this condition require a comprehensive approach, involving physical examinations, imaging tests, and various treatment options. Surgical procedures like the Ravitch and Nuss procedures can effectively correct the deformity, but they also come with risks and require careful pre - operative preparation and post - operative care. In New York City, the ranking of pectus excavatum surgeries depends on factors such as surgeon experience, hospital facilities, patient outcomes, and patient and family satisfaction. Parents should carefully consider these factors when choosing a hospital and surgeon for their child's surgery. If your 13 - year - old has pectus excavatum, we encourage you to consult with a pediatric chest wall surgeon to discuss the best treatment options for your child. Share this article with other parents who may be facing similar situations to help them make informed decisions about their child's health.