KidsMD Health Topics

Chest Wall Deformities

  • Overview

    Chest wall deformities are fairly common structural deformities in the chest.

    There are two basic kinds:

    • Funnel chest - a depression in the breastbone
      • occurs in about one out of 500 children
      • can cause breathing problems
    • Pigeon breast - the breastbone is pushed outward
      • occurs in about one out of 1,500 children
      • is much more common in boys
      • can cause scoliosis (curvature of the spine)

    When is the best time to do the surgery for funnel chest?

    Twenty-five years ago, surgeons operated when the child was as young as 4. The cartilage content of the bones made repositioning easier and healing was faster.

    But too often, the condition would recur, especially during growth spurts.

    So surgeons at Boston Children's Hospital's Department of Surgery surgeons prefer to operate, if they operate at all, during the child's teen years. By then, they're through most of their growth spurts so recurrence isn't as much of a problem.

    Boston Children's Hospital 
    300 Longwood Ave
    Boston MA 02115


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    Boston Children's Hospital
    300 Longwood Avenue
    Fegan 2
    Boston MA 02115


  • In-Depth

    What are characteristics of funnel chest and pigeon breast?

    Funnel chest is a depression or hollow caused when the breastbone, the bone in the middle of the ribcage, is pushed abnormally inward.

    It's either congenital (present at birth) or it develops within months of birth.

    • Mild cases, on occasion, correct themselves, usually by the time a child is 3.
    • In moderate and severe cases however, funnel chest may grow progressively worse and require surgery.

    True funnel chest exists when the chest remains sunken even when your child exhales or is resting.

    • When a child with funnel chest is examined either sitting or lying on the back, face up, the hollow in the chest is unchanged or rigid.
    • For those children who undergo surgery, normal breathing returns.
    • In fact, the outlook is excellent for 90 to 95 percent of those who are treated for this problem; for about one in 30 children, a second operation may be required.

    Pigeon Breast - Pigeon breast is caused when the breastbone is pushed outward.

    Girls usually develop pigeon breast at a somewhat younger age then boys, who do not develop the condition until adolescence, usually from 11 to 14 years of age.

    As with funnel chest, this condition may interfere with your child's physical health. The deformity often increases in severity each year until a child reaches full growth. Scoliosis is associated with this condition and becomes more controllable after treatment.

    Surgery can correct pigeon breast and the outlook for children who have the operation is excellent.

    What causes chest wall deformities?

    We don't know. Some studies investigating a genetic component are underway. Although the majority of cases don't involve a family history, there are many that do—enough to warrant the suspicion that genes play a significant role. The genetic story is likely to be complex, though.

    If pigeon breast is present during infancy, it may be associated with premature fusion of the segments of the breastbone, a short wide breastbone, and congenital heart disease.

    When do these deformities first appear?

    Doctors often see both deformities in newborns and during early childhood. Other times, though, it may not be apparent until the child is 9 or 10. It's rare for either excavatum or carinatum to show up after that. The typical course is from mild to more severe, with growth spurts contributing most to severity.

    What are the symptoms of chest wall deformities?

    In infancy, symptoms of funnel chest can include:

    • frequent lingering colds that often develop into pneumonia
    • a hollow depression in the chest that may be broad and shallow, deep and narrow or asymmetric
    • difficulty breathing

    In older children, symptoms of funnel chest can include:

    • breathing difficulty upon exertion or exercise
    • chest pain
    • frequent respiratory infections
    • some children have a lateral curvature of the spine, absence of the curve of the upper back, hooked shoulders and a broad thin chest

    Symptoms of pigeon chest include:

    • difficulties playing and exercising
    • tenderness and intermittent pain in the area of overgrown cartilage

    The symptoms of chest wall deformities may resemble other conditions or medical problems. Always talk to your child's physician for a diagnosis.

  • Tests

    How are chest wall deformities diagnosed? 

    Your child's doctor can diagnose a chest wall deformity after observing your child after she inhales, exhales and rests.

    The physician also calculates the depth of the chest from front to back using x-ray films of the chest to determine whether the diameter is shorter than average (funnel chest) or longer than average (pigeon breast).

    The heart is usually widened and displaced to the left. Lung capacity can be measured by exercise tests and lung scans, which often reveal mismatched lungs.

    Other tests your child's doctor might recommend include:

    • Electrocardiogram (ECG or EKG) - A test that records the electrical activity of your child's heart, shows abnormal rhythms, and detects heart muscle stress.
    • Echocardiogram (echo) - A test that evaluates the structure and function of your child's heart by using sound waves recorded on an electronic sensor, which produce a moving picture of the heart and heart valves.
  • How are chest wall deformities treated?

    For mild cases of either condition, there's really no reason for intervention.

    • A shallow funnel chest is unlikely to affect the operation of the heart or lungs at all.
    • A mild pigeon breast, if anything, gives the thoracic organs more room to function.
    • Appearance, too, is normal in these cases.

    What if my child's case is more severe?

    Funnel chest

    A severe funnel chest can impinge on your child's heart and lungs, but it's important not to overstate the risks.

    • At extremes of exercise, there is a slight deficit in the volume of blood the heart can pump out with each beat. That's because the heart has less room to fill when it relaxes.
    • Pulmonary function tests also show a slight deficit in severe cases of funnel chest. But again, this occurs only at extremes of exercise.

    These children are not at any elevated risk for sudden death.

    Pigeon breast

    With severe cases of pigeon breast, the problem is one of form rather than physiology.

    Some children with severe conditions are perfectly content with the shape of their chests. But those who suffer psychologically can suffer deeply.

    What are our treatment options?

    Funnel chest

    Funnel chest can be surgically repaired. There are two options:

    The Welsh - The surgeon makes an incision in your child's chest wall, removes the cartilage wedged between the ribs and breastbone, and then repositions the freed-up breastbone.

    • A bar is left in the chest wall to maintain the right shape for six months, during which time the child has to refrain from activities that might involve a collision, like football.
    • The technique leaves a scar visible on the chest, but fixes the problem.

    The Nuss - The incisions are made on the side, a bar is inserted laterally through the chest and the breastbone is lifted forward.

    • No cartilage is removed.
    • Scarring is less extensive.

    On the other hand, any asymmetry that's there before the operation will remain to some degree. And there's just as much pain throughout recovery. Also, the bar has to stay in for at least a year, and sometimes two. Surgeons at Children's specialize in both techniques.

    Pigeon breast

    As for fixing a severe pigeon breast, doctors at Children's recommend bracing, as pressure over time reforms the chest wall.

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