eMedicine Specialties > Pediatrics: General Medicine > Pulmonology

Pectus Excavatum: Differential Diagnoses & Workup

Author: Andre Hebra, MD, Chief, Division of Pediatric Surgery, Medical University of South Carolina; Professor of Surgery and Pediatrics, Medical University of South Carolina
Contributor Information and Disclosures

Updated: Sep 21, 2009

Differential Diagnoses

Marfan Syndrome

Other Problems to Be Considered

Conditions associated with pectus excavatum include Marfan syndrome, Poland syndrome, and Pouter pigeon breast.

Workup

Laboratory Studies

  • No specific laboratory study is necessary in the workup of patients with pectus excavatum. Most children with this condition are otherwise healthy.

Imaging Studies

  • Imaging studies are important in the initial assessment of any patient with pectus excavatum.
  • Radiography: Perform baseline 2-view chest radiography (anteroposterior and lateral views) in all patients. This provides information about any possible associated intrathoracic pathology, severity of the lung compression, and mediastinal displacement. Plain chest radiography also shows the degree of posterior displacement of the sternum, particularly in relation to the spine. However, it does not provide any information about the appearance of the affected ribs because the cartilaginous part is the involved part and is not visible on standard radiographs. In addition, plain chest radiography allows for assessment of the spine and possible associated scoliosis, a common finding in many patients with pectus excavatum.
  • Chest CT scanning
    • This is useful in determining the Haller index, which is derived by dividing the transverse chest diameter by the anteroposterior diameter. An index of more than 3.2 has been correlated with a severe deformity that requires surgery. The author's experience has demonstrated that the chest index can also be obtained with plain anteroposterior and lateral chest radiography. However, this is not as precise as the measurements obtained from CT scanning.
    • CT scanning can provide helpful information related to the commonly seen asymmetry of the chest in patients with pectus excavatum. It also clearly reveals the displacement and rotation of the heart.
    • In cases with significant asymmetry, CT scanning can provide valuable information for planning the operative intervention and can also provide helpful information regarding the asymmetric volume difference between the right and left hemithorax. Many patients with pectus excavatum have some degree of rib hypoplasia, which may cause one hemithorax to be much smaller than the other. This typically cannot be corrected by surgery.
    • Media file 8 is a CT scan of a young patient with severe pectus excavatum.

      Preoperative CT scan of the chest of 12-year-old ...

      Preoperative CT scan of the chest of 12-year-old girl with severe pectus excavatum (see Media file 5). Note the severe pectus excavatum with compression of the lung fields and complete displacement of the heart and mediastinal structures to the left hemi-thorax.

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      Preoperative CT scan of the chest of 12-year-old ...

      Preoperative CT scan of the chest of 12-year-old girl with severe pectus excavatum (see Media file 5). Note the severe pectus excavatum with compression of the lung fields and complete displacement of the heart and mediastinal structures to the left hemi-thorax.

  • Echocardiography: Cardiac function and morphology can be easily assessed with noninvasive methods such as echocardiography. Unless the patient is symptomatic, echocardiography is not mandatory in the workup of patients with pectus excavatum. However, if Marfan syndrome is suspected, echocardiography should be performed to evaluate for possible aortic root dilation. In such cases, consultation with a pediatric cardiologist should be considered.

Other Tests

  • Pulmonary volumes, ventilation, and exercise tolerance can be easily evaluated in a pulmonary laboratory with a standard pulmonary function test (PFT). Findings in patients with pectus excavatum are described in History. A progressive (stress) exercise test may help detect abnormalities in exercise response. Most patients have abnormal stress PFT findings.
  • Echocardiography, ECG, PFTs, and CBC count are not mandatory and are obtained only if indicated based on the medical history and physical examination findings. Mitral valve prolapse is not unusual in patients with pectus excavatum. The PFT results may show a slight decrease in pulmonary volumes and reserve. For more details about cardiopulmonary assessment, see History.

Procedures

  • The operative procedure for correction of pectus excavatum is discussed in Surgical Care.

Histologic Findings

  • Histologic assessment of the affected ribs, cartilage, and sternum typically does not reveal any abnormal findings other than the unusual shape of the deformed ribs.

More on Pectus Excavatum

Overview: Pectus Excavatum
Differential Diagnoses & Workup: Pectus Excavatum
Treatment & Medication: Pectus Excavatum
Follow-up: Pectus Excavatum
Multimedia: Pectus Excavatum
References
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References

  1. Kelly R, Shamberger R, Hebra A, et al. Prospective Multicenter Study of Surgical Correction of Pectus Excavatum: Design, Perioperative Complications, Pain, and Baseline Pulmonary Function Facilitated by Internet-Based Data Collection. J Am Col Sur. 2007;205:205-16. [Medline].

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  3. Weg JG, Krumholz RA, Harkleroad LE. Pulmonary dysfunction in pectus excavatum. Am Rev Respir Dis. Nov 1967;96(5):936-45. [Medline].

  4. Quigley PM, Haller JA, Jelus KL, et al. Cardiorespiratory function before and after corrective surgery in pectus excavatum. J Pediatr. May 1996;128(5 Pt 1):638-43. [Medline].

  5. Peterson RJ, Young WG, Godwin JD, et al. Noninvasive assessment of exercise cardiac function before and after pectus excavatum repair. J Thorac Cardiovasc Surg. Aug 1985;90(2):251-60. [Medline].

  6. Ravitch MM. The operative treatment of pectus excavatum. Ann Surg. 1949;122:429-444.

  7. Nuss D, Kelly RE Jr, Croitoru DP. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg. Apr 1998;33(4):545-52. [Medline].

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  22. Hebra A, Jacobs JP, Feliz A, Arenas J. Minimally invasive repair of pectus excavatum in adult patients. Am Surg. Sep 2006;72(9):837-842. [Medline].

  23. Hebra A, Swoveland B, Egbert M, et al. Outcome analysis of minimally invasive repair of pectus excavatum: review of 251 cases. J Pediatr Surg. Feb 2000;35(2):252-7; discussion 257-8. [Medline].

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  26. Ravitch MM. Pectus excavatum. In: Congenital Deformities of the Chest Wall and Their Operative Correction. Philadelphia, Pa: WB Saunders Co; 1977.

  27. Robicsek F. Surgical treatment of pectus excavatum. Chest Surg Clin N Am. May 2000;10(2):277-96. [Medline].

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  29. Tschirkov A, Baev B, Iliev R. Simultaneous pectus and open heart surgery. Chest Surg Clin N Am. May 2000;10(2):405-13, viii-ix. [Medline].

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Further Reading

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Keywords

pectus excavatum, congenital chest wall deformity, sunken chest, pectus, Marfan syndrome, Poland syndrome, minimally invasive repair of pectus excavatum, MIRPE, Nuss technique, open Ravitch technique for repair of pectus excavatum, mitral valve prolapse, scoliosis, carinatum, pectus posture, bone and cartilage overgrowth, sternal turn-over operation, pectus carinatum, pectus deformity, back pain

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Contributor Information and Disclosures

Author

Andre Hebra, MD, Chief, Division of Pediatric Surgery, Medical University of South Carolina; Professor of Surgery and Pediatrics, Medical University of South Carolina
Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Association for Academic Surgery, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, and Southern Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Girish D Sharma, MD, Associate Professor, Department of Pediatrics, Rush University Medical Center, Rush Children's Hospital; Director of Pediatric Pulmonary Section and Rush Cystic Fibrosis Center
Girish D Sharma, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Royal College of Physicians of Ireland
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Heidi Connolly, MD, Associate Professor of Pediatrics and Psychiatry, University of Rochester; Director, Pediatric Sleep Medicine Services, Strong Sleep Disorders Center
Heidi Connolly, MD is a member of the following medical societies: American Academy of Pediatrics, American Thoracic Society, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

CME Editor

Mary E Cataletto, MD, Associate Director, Division of Pediatric Pulmonology, Winthrop University Hospital; Professor of Clinical Pediatrics, State University of New York at Stony Brook; Director of Children's Sleep Services, Winthrop University Hospital
Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians
Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Chief Editor

Michael R Bye, MD, Professor of Clinical Pediatrics, Division of Pulmonary Medicine, Columbia University College of Physicians and Surgeons; Attending Physician, Pediatric Pulmonary Medicine, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center
Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, and American Thoracic Society
Disclosure: Merck Honoraria Speaking and teaching

 
 
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