Diseases

Funnel chest (Pectus excavatum)

Funnel chest (Pectus excavatum)


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In the case of a funnel chest (lat. Pectus excavatum), the front wall of the chest sinks - the shape is reminiscent of a funnel because the region around the sternum leans inwards. Cartilage deforms between the breastbone and ribs.

Funnel breast - the most important facts

  • Definition: A funnel breast is a congenital deformation of the cartilage between the breastbone and ribs.
  • Appearance: The front wall of the chest sinks inward towards the spine, a hump can form and the shoulders bend forward.
  • Frequency: The congenital malformation of the chest occurs relatively frequently, for example in one out of 300 to 400 births. Boys with a ratio of approx. 3: 1 are affected significantly more often than girls.
  • Risks: With severe deformations, the performance of the heart and lungs can decrease.
  • Therapy for funnel breasts: Physiotherapy can stop the consequences of the deformity, but it cannot lift the funnel breast itself. To correct this, there are minimally invasive and open surgical procedures.

Symptoms of funnel breast

The anatomical consequences differ depending on how pronounced the malformation of the chest is. The shoulders lean forward and hang, and a hump arises on the back as the belly bulges forward.

A less strong funnel breast is usually an aesthetic problem - not a health problem. Depending on the form, however, the heart and lungs can also be affected.

In the case of a highly developed malposition, however, the heart has less space and therefore it can pump less blood. This is particularly evident in physical exertion. The performance drops. During long-distance running, those affected quickly get "out of breath", when dragging furniture they feel short of breath, when chopping wood, a racing heart.

These symptoms have been shown to cease when the deformation is corrected by surgery. Patients often show a reduced lung volume because the deformation in the chest also limits the space for the lungs. So those affected cannot take a deep breath.

Psychological consequences

Those affected often have a psychological strain on the deformation. They find them ugly and often develop avoidance behavior. So they don't go to places where others see their funnel breasts, refrain from going to the swimming pool or cover their breasts with clothes when they sit on the beach in summer.

Especially during puberty, a funnel breast has a negative impact on sexual self-esteem, so that some people shy away from approaching the opposite sex. Sometimes this even leads to a general avoidance of contacts with other people. Bullying of classmates, teasing and insulting those affected also occur.

Frequency

The frequency range from an incidence of 1: 300 to 1: 1000 births. However, most specialists and clinics cite an incidence of 1: 300 to 1: 400, including three times as many boys as girls. Every third person already has cases of this deformation in the family. It also occurs more often in certain diseases - fetal alcohol syndrome (fetuses whose mothers suffer from alcoholism), Marfan syndrome and Poland syndrome.

Causes of a funnel breast

The causes of this deformation are still unknown. The family cluster indicates that genetic components play a role. Excessive growth of the costal cartilage could trigger the deformation, but that too remains unclear.

Diagnosis and examination

A funnel breast can usually be seen on the outside at birth. The examination is about the effects it has on the health of those affected.

The Haller index

The Haller index measures the longest distance between the right and left ribs, divided by the smallest distance between the spine and sternum. With a normal anatomy, this quotient is around 2.5. The larger it is above this average, the more pronounced is the funnel breast.

Spirometry

Spirometry is a procedure in which the doctor measures the breath at rest to see how well the lungs are working. Above all, it is about how much air a patient breathes in and out and how much this vital capacity differs from a healthy person.

Spiroergometry

Lung function during exercise is measured with spiroergometry. Those affected ride a stationary bike and continuously increase their physical performance. The doctor now measures the lung volume, heart rate, blood pressure, takes an EKG and measures the blood gas values. This shows how the heart, lungs and muscles work, and also which of the three are restricted in their function.

Echocardiography

Here the doctor examines the cardiac functions with ultrasound. In this way it can be seen whether the heart's function is restricted. As a rule, this examination is carried out during physical exertion, since the symptoms of a funnel chest usually only become apparent after this.

Magnetic resonance imaging

Magnetic resonance imaging, also known as magnetic resonance imaging (MRI), shows a section of the body, once after inhaling and once after exhaling. This imaging procedure shows how flexible the chest is and how the deformation affects the anatomy and position of the heart.

Funnel breast treatment

There are generally three ways to treat a funnel breast:

  1. a suction bell,
  2. a surgery
  3. and physiotherapy.

Physiotherapy, especially in the growing phase of young people, can help to avoid surgery later on by correcting incorrect posture caused by the deformity of the chest. However, the funnel breast itself cannot fix it.

After an operation, physiotherapy is necessary to prevent malpositions due to incorrect body movements in the healing phase.

The suction cup is a novel procedure in which specialists hope that in the future it will make many operations of a funnel breast superfluous.

Physiotherapy for funnel breasts

Physiotherapy is particularly important for those affected during puberty. During this time, a decision is made as to whether a faulty posture results permanently from the deformed breast.

The following exercises are particularly useful in times of growth:

Strengthen your back

The hands are clasped behind the head. The elbows move as far back as possible, the head and neck remain stretched. So the chest presses forward. The stretched trunk is stretched forward in the hip. He stays in this position for about three seconds. People should repeat this exercise 25 times a day. It serves to strengthen the back and prevents the shoulders from leaning forward.

Exercise the pectoral muscles

To do this, lie on your back on the floor, stretch your arms and take light weights, for example dumbbells, in both hands. Then bring your straight arms together over your chest. Repeat the exercise 25 times a day.
You should also do pushups about 25 a day.

Widen your chest

To do this, keep your chest straight, stretch your shoulders back, take a deep breath and hold your breath for as long as possible. You should do this twice a day, breathing in 20 times each time.

Endurance sports

This is about increasing the muscles and physical performance or keeping them at an elevated level. Regular sporty cycling is advisable, ideally around one hour every day. Swimming on the course, 1000-meter runs and / or regular jogging are also suitable. Hiking can also be an endurance sport if you take longer tours and are not on the simplest of terrain (for example, you can take easier mountain hikes).

Generally, you increase physical endurance if you do as much as possible on foot - climbing stairs instead of elevator, walking two or three tram stops instead of using the train, etc.

Prevent incorrect loads

Physiotherapy, as described, cannot correct the funnel chest - but it can prevent incorrect posture and consequential damage. This includes damage to the intervertebral discs caused by incorrect loading. Here, a trained back muscle balances the stress from the funnel chest.

Suction cup for funnel breast

A fairly new method is to gradually raise the chest of the person affected by the daily application of a suction bell, particularly in the growth phase, and thus permanently correct the funnel breast. In contrast to pure physiotherapy, it should not only be possible to counteract malpositions due to the deformation without surgery, but also to eliminate the deformation itself.

It is already clear that the duration of such treatment and their prospects of success depend heavily on the age of the affected person (the younger, the better), the extent of the deformation and how often the affected person uses the suction cup.

So far, the deformation has actually been reduced in some cases. However, since this method has only been used for a few years, there is no evidence of long-term effects. So we do not know whether the correction by the funnel chest only lasts for some time and whether the deformation then returns, or whether the correction is permanent.

Funnel-breast surgery

Surgery is often necessary. On the one hand, the extent of the physical impairment decides. Intervention is therefore indicated if

  • those affected are restricted in their movements by a hump or shoulders sloping forward,
  • the funnel chest leads to misalignments that affect the skeleton
  • and / or if the heart and lungs suffer from the deformation.

Surgery is also the first choice if the affected person is not restricted in their health, but suffers from the malformation in a psychological manner.

Such operations aim to give the chest wall a new, "normal" shape, or to correct the aesthetics that are intolerable to those affected with a 3D implant. Pediatric surgeons and thoracic surgeons perform these operations, as does plastic surgery. There are various methods of how such an intervention works, roughly they can be differentiated into a minimally invasive intervention and an open correction.

Minimally invasive correction

This is the most common surgical method to correct a funnel breast. Compared to conservative surgery, it means much shorter treatment and usually also much shorter lasting pain for those affected. The minimally invasive method works best when the body's growth has just ended, i.e. between the ages of 16 and 20.

This procedure is carried out by mirroring the chest. A U-shaped bar, the size of which is adapted to the chest, is pushed under the funnel bottom of the chest and fixed to the side of the ribs. The breastbone now lifts through the bow until it is in the normal position.

This procedure is minimally invasive because there is no need to “cut around” the bones and cartilages and no major cuts are required to open the chest. Only on the side of the rib cage are relatively small accesses made for the latch.

This minimally invasive procedure is by no means pain-free. Those affected need longer-lasting and initially massive therapy with painkillers. The reason for this is that the sternum urges to return to its "funnel-breast position"; the bracket prevents it from doing so, and that hurts first, more precisely, it causes pressure and tension pain. The chest also moves constantly through breathing. This causes the temple to rub against the periosteum, which also causes pain.

This pain decreases continuously in the weeks after the operation if there are no complications. Those affected usually stay in the hospital for a few days and cannot work for several weeks. The temple stays in the body for around three years, when the normal position is usually "overgrown". The removal of the temple is associated with little pain.

The open operation

This classic operation is necessary if the affected person shows a strong deformation, which also causes an asymmetry of the chest. A bracket under the breastbone is not sufficient to correct the deformation towards normal. Instead, the cartilage that causes the malposition must now be severed. Then it is erected and fixed with sutures until the breastbone is in the normal position. Metal parts often have to be implanted to achieve this stability.

In contrast to the minimally invasive procedure, there is no pressure on the breastbone, because this was removed by straightening the deformed ankle. In this way, the metal can be removed after just one year, and not only after three years. Unlike the minimally invasive procedure, a visible scar remains on the front of the chest.

Risks of funnel breast surgery

Any surgical procedure can lead to complications. In the case of funnel breast corrections, these are particularly disorders of wound healing, infections and allergic reactions to the metal of the implants. General risks associated with general anesthesia surgery include thrombosis, bleeding and pulmonary embolism. These occur very rarely with this correction.

What should you watch out for after the procedure?

Sufferers should not turn their torso in the first six weeks after surgery or avoid such rotations as much as possible. For two weeks, you should not raise your arms above your head and only sleep on your back for four weeks. However, walking is not a problem, you should test your own pain sensation and reduce the pain medication accordingly. Patients have to give up exercise six weeks after the procedure.

Physiotherapy begins in the sixth to twelfth week, and those affected gradually increase physical activities. Now they can drive a car without painkillers. Sports can be started again slowly, swimming, jogging or cycling are recommended. Sports that involve rapid body rotations and chest strain, such as weight lifting or shot put, should be avoided.

From the twelfth week, normal everyday life returns. You can carry heavy backpacks and do sports with almost no restrictions. However, they should not practice contact sports in the long term, at least until the sternum has regrown. This applies to tough sports like rugby, American football and ice hockey, but also to karate, wrestling, wrestling and the like.

Funnel breast - what does the health insurance company pay?

The health insurance companies pay for the diagnostics in full. The treatment is about whether the affected person is physically impaired or can be corrected for cosmetic reasons. If there is a physical impairment, the health insurers will bear the costs without any problems. In the case of a cosmetic operation, the health insurers generally only bear the costs if there is a psychological report that certifies that the person affected has a greater psychological burden due to the malposition. (Dr. Utz Anhalt)

Author and source information

This text corresponds to the specifications of the medical literature, medical guidelines and current studies and has been checked by medical doctors.

Swell:

  • Lange, Sebastian (ed.): Radiological diagnosis of thoracic diseases: textbook and atlas, Georg Thieme Verlag, 2010
  • Koshi, Rachel: Cunningham's Manual of Practical Anatomy VOL 2 Thorax and Abdomen, Oxford University Press, 2017
  • Schwabegger, Anton H. (ed.): Congenital Thoracic Wall Deformities: Diagnosis, Therapy and Current Developments, Springer Vienna, 2018
  • Universitätsklinikum Leipzig - Clinic and Polyclinic for Pediatric Surgery: funnel breast. Correction of the funnel chest using the minimally invasive technique according to NUSS. (Call: November 14, 2019), University Hospital Leipzig
  • Kliniken der Stadt Köln gGmbH - Lung Clinic Merheim: Patient information funnel chest. (Accessed: November 14, 2019), Cologne Clinics
  • Creswick, Heather A .; Stacey, Michael W .; Kelly Jr., Robert E. et al .: Family study of the inheritance of pectus excavatum, in: Journal of Pediatric Surgery, 41/10: 1699-1703, October 2006, Journal of Pediatric Surgery
  • Brochhausen, Christoph; Turial, Salmai; Müller, Felix K.P. et al .: Pectus excavatum: history, hypotheses and treatment options, in: Interactive CardioVascular and Thoracic Surgery, 14/6: 801-806, June 2012, Oxford University Press
  • Maagaard, Marie; Tang, Mariann; Ringgaard, Steffen et al .: Normalized Cardiopulmonary Exercise Function in Patients With Pectus Excavatum Three Years After Operation, in: The Annals of Thoracic Surgery, 96/1: 272-278, July 2013, ScienceDirect

ICD codes for this disease: Q67.6ICD codes are internationally valid encryption codes for medical diagnoses. You can find yourself e.g. in doctor's letters or on disability certificates.


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