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Pectus Carinatum Treatment & Management

  • Author: Mary E Cataletto, MD; Chief Editor: Michael R Bye, MD  more...
 
Updated: Oct 13, 2015
 

Medical Care

Most motivated patients with pectus carinatum, especially those younger than 18 years with malleable chest walls, benefit from orthotic bracing, and this is generally the first line of therapy.[13, 14]  Success rates of 65-80 % and long-term outcomes with orthotic bracing alone are encouraging.[9]

A study by Lee at el (2012) describes the preliminary results of 98 children treated using the Calgary Protocol, which involves a self-adjustable, low-profile bracing system used in 2 phases. The first phase involves 24 h/d bracing until correction is achieved. The second phase is a maintenance phase during which the brace is worn only at night until axial growth is complete. Twenty-three children completed treatment with good patient satisfaction and improved appearance, suggesting that when used in this fashion, it is an effective treatment for pectus carinatum. Therapy failed in 42 children, owing to either noncompliance or they were lost to follow-up. Two required surgical intervention after bracing failed to correct the problem. Additional studies and follow-up of the children still on protocol is important.[15]

For older patients with more rigid chest walls, bracing may not be effective and surgery may be the initial consideration.

Casting followed by bracing or bracing alone eliminates the risks of surgery and anesthesia and does not preclude surgery if unsuccessful.

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Surgical Care

Endoscopic resection of costal cartilage with a sternal osteotomy

Because many corrections are performed for cosmetic reasons, decreasing the size of incisions is important.

In 1997, Kobayashi reported 2 patients in whom the pectus carinatum deformity was corrected with limited incisions using an endoscopic approach.[15] They suggest that this approach is better indicated in preschool-aged children because of their skin quality and tone, as well because of the increased ease of costal dissection compared with adult patients.

In 2008, Fonkalsrud reported a series of 260 patients who underwent surgical correction of pectus carinatum deformities over a period of 37 years.[4] He concluded that, over time, the trend towards less extensive open techniques has resulted in "low morbidity, mild pain, short hospital stay and very good physiologic and cosmetic results." His study included both pediatric and adult patients.

Open surgical repair

Various methods have been described. The reader is referred to Fonkalsrud (2008),[4] de Matos (1997),[16] Shamberger (1987),[17] Del Frari (2011),[18] and Cohee (2013)[19] for further details.

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Consultations

Pectus carinatum has been associated with congenital heart disease. In these patients, and in those with suspected or identified cardiac pathology, preoperative cardiology evaluation is recommended.

Exercise testing may be performed in consultation with either a cardiologist or a pulmonologist.

Symptomatic patients with exertional dyspnea, tachypnea, or decreased endurance, as well as those with asthma symptoms, benefit from a pulmonology evaluation.

Individuals with pectus carinatum who have significant concerns about their body image or low self-esteem can benefit from psychological counseling.

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Activity

Symptomatic patients may report decreased exercise tolerance and exertional dyspnea, which may limit activity. Fonkalsrud's series (2008) reported improvement in exertional symptoms and endurance in all symptomatic patients within 3-6 months of surgical repair.[4]

Fonkalsrud's recommendations for postoperative activity include the following[4] :

  • Use incentive spirometer and encourage periodic deep breaths.
  • Limit twisting movements of the chest for at least 4 months postoperatively.
  • Avoid rapid elevation of the arms overhead for at least 4 months postoperatively.
  • Encourage lower extremity exercise (may begin within first 2 wk after surgery).
  • Light weights may be used to strengthen biceps and deltoids; the use of chest and abdominal muscles may be increased later (after 3-4 wk).
  • Gym classes are not indicated for 5 months after surgery in school-aged children.
  • Long-term recommendations include stretching exercises that involve pulling the shoulder blades posteriorly to improve posture.
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Contributor Information and Disclosures
Author

Mary E Cataletto, MD Professor of Clinical Pediatrics, State University of New York at Stony Brook

Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Charles Callahan, DO Professor, Chief, Department of Pediatrics and Pediatric Pulmonology, Tripler Army Medical Center

Charles Callahan, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American College of Osteopathic Pediatricians, American Thoracic Society, Association of Military Surgeons of the US, Christian Medical and Dental Associations

Disclosure: Nothing to disclose.

Chief Editor

Michael R Bye, MD Professor of Clinical Pediatrics, State University of New York at Buffalo School of Medicine; Attending Physician, Pediatric Pulmonary Division, Women's and Children's Hospital of Buffalo

Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

Girish D Sharma, MD, FCCP, FAAP Professor of Pediatrics, Rush Medical College; Director, Section of Pediatric Pulmonology and Rush Cystic Fibrosis Center, Rush Children's Hospital, Rush University Medical Center

Girish D Sharma, MD, FCCP, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, Royal College of Physicians of Ireland

Disclosure: Nothing to disclose.

References
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  2. Steinmann C, Krille S, Mueller A, Weber P, Reingruber B, Martin A. Pectus excavatum and pectus carinatum patients suffer from lower quality of life and impaired body image: a control group comparison of psychological characteristics prior to surgical correction. Eur J Cardiothorac Surg. 2011 Nov. 40(5):1138-45. [Medline].

  3. Derveaux L, Clarysse I, Ivanoff I, Demedts M. Preoperative and postoperative abnormalities in chest x-ray indices and in lung function in pectus deformities. Chest. 1989 Apr. 95(4):850-6. [Medline].

  4. Fonkalsrud EW. Surgical correction of pectus carinatum: lessons learned from 260 patients. J Pediatr Surg. 2008 Jul. 43(7):1235-43. [Medline].

  5. Iakovlev VM, Nechaeva GI, Viktorova IA. [Clinical function of the myocardium and cardio- and hemodynamics in patients with pectus carinatum deformity]. Ter Arkh. 1990. 62(4):69-72. [Medline].

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  11. Castile RG, Staats BA, Westbrook PR. Symptomatic pectus deformities of the chest. Am Rev Respir Dis. 1982 Sep. 126(3):564-8. [Medline].

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  13. Lee RT, Moorman S, Schneider M, Sigalet DL. Bracing is an effective therapy for pectus carinatum: interim results. J Pediatr Surg. 2013 Jan. 48(1):184-90. [Medline].

  14. Wong KE, Gorton GE 3rd, Tashjian DB, Tirabassi MV, Moriarty KP. Evaluation of the treatment of pectus carinatum with compressive orthotic bracing using three dimensional body scans. J Pediatr Surg. 2014 Jun. 49 (6):924-7. [Medline].

  15. Kobayashi S, Yoza S, Komuro Y, Sakai Y, Ohmori K. Correction of pectus excavatum and pectus carinatum assisted by the endoscope. Plast Reconstr Surg. 1997 Apr. 99(4):1037-45. [Medline].

  16. de Matos AC, Bernardo JE, Fernandes LE, Antunes MJ. Surgery of chest wall deformities. Eur J Cardiothorac Surg. 1997 Sep. 12(3):345-50. [Medline].

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  18. Del Frari B, Schwabegger AH. Ten-year experience with the muscle split technique, bioabsorbable plates, and postoperative bracing for correction of pectus carinatum: the Innsbruck protocol. J Thorac Cardiovasc Surg. 2011 Jun. 141(6):1403-9. [Medline].

  19. Cohee AS, Lin JR, Frantz FW, Kelly RE Jr. Staged management of pectus carinatum. J Pediatr Surg. 2013 Feb. 48(2):315-20. [Medline].

  20. Bostanci K, Ozalper MH, Eldem B, Ozyurtkan MO, Issaka A, Ermerak NO. Quality of life of patients who have undergone the minimally invasive repair of pectus carinatum. Eur J Cardiothorac Surg. 2013 Jan. 43(1):122-6. [Medline].

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Pectus carinatum. Photograph courtesy of K. Kenigsberg, MD.
Chest radiograph of a patient with pectus carinatum. Radiograph courtesy of A. Fruauff, MD.
CT scan of a patient with pectus carinatum. CT courtesy of A. Fruauff, MD.
 
 
 
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