Chest wall indentation can vary in severity

The 13-year-old wasn't too thrilled with the increasing "dent" in the middle of her chest. But, while physical appearance is certainly important to most teens, it was really the negative impact of this concave chest shape on the girl's heart and lung function that spurred her pediatric surgeon to recommend surgical repair.

The junior high student had pectus excavatum, a chest wall deformity which varies greatly in depth from trivial to severe. Dr. Dawn Jaroszewski and colleagues in the Journal of the American Board of Family Medicine describe PE as a depression of the sternum (breast bone) and its surrounding rib cartilage which often increases in severity until full skeletal maturity is reached.

PE is, in fact, the most common of the chest wall deformities, with the condition affecting boys more often than girls. A genetic link has not been well-defined, but studies show that about 40 percent of individuals with various pectus deformities have relatives with similar chest wall abnormalities.

The family practice team finds that severity of chest wall indentation does not always correlate with severity of symptoms. If a patient does become symptomatic with PE, the most common complaints tend to be shortness of breath with mild exercise and progressive loss of endurance. These symptoms are thought to be related to the heart compression and decreased chest volume seen in some children with PE.

The authors explain that medical testing can help identify structural and functional impairments in cases of pectus excavatum. Testing can include a chest CT or MRI to obtain measurements as well as an EKG to record any associated rhythm abnormalities.

Echocardiogram can be used to screen an affected child for cardiac compression, mitral valve prolapse (the "floppy" valve found in about 25 percent of PE patients), or any abnormalities of the aortic root or valve which can be seen in Marfan syndrome patients. Pulmonary function and cardiopulmonary exercise testing can also be performed to evaluate for functional limitations due to chest wall deformity.

Jaroszewski's group advises referral to a surgeon if a child with pectus excavatum meets any one of a number of criteria including, among others, feeling symptomatic, showing evidence of cardiac compression, or experiencing "significant body image disturbance." Surgery is often recommended if two or more of such criteria are met.

Pectus excavatum surgery is usually done during adolescence using either a modification of the traditional open approach or the more recently introduced minimally invasive bar-placement procedure. Success of a PE repair, according to the family practitioners, hinges on receiving treatment "at a high-volume center with a surgeon dedicated to pectus repair."

In a large multicenter study published in the journal "Pediatrics," Dr. Robert E. Kelly and colleagues find that after undergoing successful pectus excavatum repair, pediatric patients and their parents note significant improvements in the children's physical function. A positive change in body image also occurs after surgery, with an impressive 97 percent of post-op patients reporting that surgery improved their chest appearance.

• Dr. Helen Minciotti is a mother of five and a pediatrician with a practice in Schaumburg. She formerly chaired the Department of Pediatrics at Northwest Community Hospital in Arlington Heights.