Introduction to Pectus Excavatum
Pectus excavatum, also known as sunken chest syndrome or funnel chest, is a relatively common chest wall disorder in children. According to Nationwide Children's Hospital, it occurs in approximately one out of 1,000 children. The disorder is characterized by a concavity of the sternum, where the breastbone is sunken inward, leaving a dent in the chest. It is about five times more common in boys than girls and is usually noted at birth as a mild condition but can become progressively more pronounced over time, especially during growth spurts like puberty.
Symptoms of Pectus Excavatum
The symptoms of pectus excavatum can vary depending on the age of the child and the severity of the condition.
- In infants: As described by Boston Children's Hospital, symptoms can include a hollow depression in the chest that may be broad and shallow, deep and narrow, or irregular. Infants may also have more rapid breathing than normal.
- In older children and adolescents: Common symptoms include shortness of breath upon exertion or exercise, chest pain, a lateral curvature of the spine and absence of the curve of the upper back, hooked shoulders, and a broad, thin chest. Some may also experience problems with poor posture, such as slumped shoulders and a protruding abdomen, or what is sometimes referred to as a “pot belly,” as noted by Johns Hopkins Children's Center. Severe cases can shift the heart to the left side of the chest and compress the lungs, limiting the child's ability to take deep breaths. Additionally, approximately 15 percent of children with pectus excavatum also develop scoliosis (curvature of the spine), and in rare cases, it can be associated with connective tissue disorders such as Marfan syndrome or Ehlers - Danlos syndrome (EDS).
Causes of Pectus Excavatum
The exact cause of pectus excavatum is unknown. However, since enough children with the condition have a family history, doctors suspect that genes may play a significant role. Researchers are currently investigating a genetic component. According to Johns Hopkins Children's Center, an overgrowth of the rib cartilages before and after birth causes the characteristic depression of the sternum, and this overgrowth commonly accelerates during puberty.
Diagnosis of Pectus Excavatum
Diagnosing pectus excavatum typically involves a combination of physical examination and medical tests.
Physical Examination
Chest wall deformities can be evident in infancy, but many also develop or become more obvious as children grow. Abnormalities are usually first noted by the parents, but may be evident only to the physician and found during routine chest examination. As the chest wall develops over time and becomes less flexible after infancy, disorders may become more or less problematic with maturation of the chest wall.
Medical Tests
- X - rays: X - rays of the chest can help the doctor confirm the diagnosis and get a general view of the chest structure.
- CT Scans: At Johns Hopkins Children's Center, a CT scan is used to calculate the Haller index. The Haller index compares the depth of the chest cavity beneath the sternum to the width of the chest cavity (from right to left). A normal ratio of width - to - depth is about 2.5 to 1, and any calculation greater than 3.25 is considered a moderate to severe defect.
- White Light Scanner: Boston Children's Hospital uses a white light scanner, a type of three - dimensional (3D) camera, to help measure the child's chest wall depression and monitor their response to treatment over time.
- Echocardiogram: This test, also known as cardiac ultrasound, is used to evaluate the function of the heart and check if the pectus excavatum is affecting the heart's performance.
- Pulmonary Function Test (PFT): A PFT measures how well the lungs are working, including how much air the lungs can hold and how quickly air can move in and out of the lungs. This can help determine if the pectus excavatum is affecting lung function.
- Cardiopulmonary Exercise Test (CPET): This test evaluates how the heart and lungs work together during exercise and can provide more information about the child's overall cardiopulmonary function in relation to the pectus excavatum.
Treatment Options for Pectus Excavatum
The treatment of pectus excavatum depends on the severity of the condition, the age of the child, and the presence of any associated symptoms or complications. Treatment options can be broadly divided into non - surgical and surgical approaches.
Non - Surgical Treatment
Non - surgical treatment is often considered for children with mild cases of pectus excavatum or those who are not suitable candidates for surgery or wish to avoid it.
- Vacuum Bell Therapy: Vacuum bell therapy uses a device worn on the outside of the body that creates suction to lift the breastbone forward over time. As mentioned by Boston Children's Hospital, it typically works best for children who are younger, have mild pectus excavatum, and have flexible chest walls. The child needs to wear the device for a total of four hours every day, and the therapy usually takes at least two years, but this may depend on the child's growth. According to Nationwide Children's Hospital, patients who choose this option typically see excellent results, with approximately 80 percent seeing an elevation greater than 1 cm within 3 months, approximately 20 percent seeing complete correction within 6 months, and approximately 13.5 percent seeing complete correction within 18 months.
- Exercises and Stretches: Along with vacuum bell therapy, exercises and stretches can be recommended to strengthen the chest muscles and improve posture. These can help support the chest wall and potentially improve the appearance and function of the chest.
Surgical Treatment
For more severe cases of pectus excavatum or when non - surgical treatments are ineffective, surgical intervention may be necessary. The two main surgical procedures are the Nuss procedure and the Ravitch procedure.
The Nuss Procedure
The Nuss procedure is a minimally invasive thoracoscopic surgery to correct the deformity by placing a prosthetic bar behind the sternum. Surgeons make small cuts on each side of the chest and insert a curved bar under the breastbone. The bar, which has been shaped to the contours of the child's chest, presses the breastbone forward. Sometimes more than one bar is needed. The bar usually remains in the chest for two to three years while the breastbone grows around it, and removing the bar is a relatively simple procedure.
This minimally invasive surgery offers several advantages compared to traditional open surgery, including smaller incisions and reduced scarring, reduced operating time, an approximate 90 percent decrease in blood loss, an early return to regular activity, and excellent cosmetic results. Many hospitals, such as Nationwide Children's Hospital, Johns Hopkins Children's Center, and Cleveland Clinic Children's, have reported high success rates with the Nuss procedure. At Cleveland Clinic Children's, over 98% of their pectus excavatum patients have been successfully treated with the Nuss procedure.
To manage pain during the Nuss procedure, an innovative technique called cryoablation is often used. The surgeon will freeze the nerves above and below the bar on each side of the chest, which temporarily decreases pain transmission through these nerves for three months following surgery. This significantly reduces pain after surgery and can lead to shorter hospital stays and a quicker recovery.
The Ravitch Procedure
The Ravitch procedure, also known as the Welch procedure, is an open surgery in which the surgeon makes a cut across the front of the chest and removes cartilage that is causing the breastbone to grow inward. The surgeon then reshapes the breastbone and may place a metal bar to hold it in place while it heals. The bar usually remains in place for six to 12 months while new cartilage grows. Although it is a more invasive procedure compared to the Nuss procedure, it can be a suitable option in certain cases, such as when the pectus excavatum is very severe or when there are other associated anatomical abnormalities.
New York City Hospitals for Children's Pectus Excavatum Treatment
New York City is home to several top - notch children's hospitals that offer excellent care for children with pectus excavatum. Let's take a look at some of these hospitals based on their rankings and expertise in treating this condition.
New York - Presbyterian Children's Hospital - Columbia and Cornell
This hospital is ranked #1 in New York according to US News Best Hospitals. It is nationally ranked in 10 children's specialties. With a vast team of experts across multiple disciplines, including pediatric surgeons, cardiologists, pulmonologists, and anesthesiologists, it has the resources and experience to provide comprehensive care for children with pectus excavatum. They are likely to offer both non - surgical and surgical treatment options, and with their high - level of specialization, they can handle complex cases and ensure the best possible outcomes for patients.
Cohen Children's Medical Center
Ranked #2 in New York and nationally ranked in 8 children's specialties, Cohen Children's Medical Center has a strong reputation for pediatric care. Their pediatric surgical team is well - equipped to perform surgeries such as the Nuss and Ravitch procedures. The hospital also likely provides support services for patients and their families, including pre - operative counseling, post - operative rehabilitation, and psychological support to help children cope with the condition and the treatment process.
Mount Sinai Kravis Children's Hospital
Mount Sinai Kravis Children's Hospital is ranked #3 in New York and nationally ranked in 4 children's specialties. The hospital offers a multidisciplinary approach to treating pectus excavatum, with experts from different fields working together to develop individualized treatment plans for each child. They may also be involved in research and clinical trials, which means patients may have access to the latest treatment techniques and therapies.
Hassenfeld Children’s Hospital at NYU Langone
With a #4 ranking in New York and being nationally ranked in 3 pediatric specialties, Hassenfeld Children’s Hospital at NYU Langone has a dedicated team of pediatric specialists. Their focus on patient - centered care ensures that children and their families are involved in every step of the treatment decision - making process. The hospital may also offer state - of - the - art diagnostic tools and treatment facilities to provide high - quality care for pectus excavatum patients.
Children's Hospital at Montefiore
This hospital is also ranked #4 in New York and nationally ranked in 3 children's specialties. The Children's Hospital at Montefiore has a long - standing commitment to pediatric health. Their team of surgeons and other medical professionals are experienced in treating pectus excavatum, and they offer a range of treatment options tailored to the individual needs of each child. Additionally, they may provide educational resources for families to help them better understand the condition and its treatment.
Factors to Consider When Choosing a Hospital for Children's Pectus Excavatum Treatment
When choosing a hospital for a child's pectus excavatum treatment, several factors should be taken into account to ensure the best possible care and outcome.
Hospital Reputation and Ranking
Hospitals with high rankings, such as those listed in the US News Best Hospitals, often have a proven track record of providing high - quality care. Rankings can be an indicator of the hospital's expertise, the success rate of their treatments, and the overall patient satisfaction. However, it's important to note that rankings are just one aspect, and other factors such as the specific expertise of the medical team for pectus excavatum should also be considered.
Medical Team Expertise
The expertise of the medical team is crucial. Look for hospitals that have a team of experienced pediatric surgeons, cardiologists, pulmonologists, and other relevant specialists. Surgeons who perform a high volume of pectus excavatum surgeries are more likely to have the skills and knowledge to handle different cases effectively. Additionally, a multidisciplinary team approach ensures that all aspects of the child's health, including any associated cardiac or pulmonary issues, are addressed.
Treatment Options Offered
It's important to choose a hospital that offers a comprehensive range of treatment options, both non - surgical and surgical. This allows for flexibility in treatment planning based on the severity of the pectus excavatum and the child's individual circumstances. For example, if a child has a mild case, non - surgical options such as vacuum bell therapy may be initially recommended, but if these are ineffective, surgical options should be available.
Patient Support Services
Going through a medical condition and its treatment can be a stressful experience for both the child and the family. Hospitals that offer patient support services, such as pre - operative counseling, post - operative rehabilitation, and psychological support, can make the treatment process more manageable. These services can help the child and family cope with the emotional and physical challenges associated with pectus excavatum treatment.
Location and Accessibility
Consider the location of the hospital and its accessibility. If the child requires multiple visits for treatment, a hospital that is close to home can reduce travel time and make it easier for the family to attend appointments. However, if the best - suited hospital for the child's condition is further away, the hospital should be able to provide assistance with travel arrangements and accommodations.
Conclusion
Pectus excavatum is a common chest wall disorder in children that can have physical and psychological impacts. Fortunately, there are effective treatment options available, ranging from non - surgical approaches like vacuum bell therapy to surgical procedures such as the Nuss and Ravitch procedures. In New York City, several top - ranked children's hospitals offer high - quality care for children with pectus excavatum. When choosing a hospital, factors such as hospital reputation, medical team expertise, treatment options, patient support services, and location should be carefully considered. By making an informed decision, parents can ensure that their child receives the best possible treatment and care for this condition.
If your child is suspected of having pectus excavatum or has already been diagnosed, don't hesitate to seek medical advice. Contact one of the reputable hospitals in New York City to schedule a consultation with a pectus excavatum expert. Share this article with other parents who may find it helpful in understanding this condition and making treatment decisions for their children.
