Pectus carinatum
| Pectus carinatum | |
|---|---|
| Classification and external resources | |
 Severe case of pectus carinatum | |
| ICD-10 | Q67.7 |
| ICD-9 | 754.82 |
| DiseasesDB | 29402 |
| MedlinePlus | 003321 |
| eMedicine | ped/1803 |
Pectus carinatum, (L carīnātus, equiv. to carīn(a) keel), also called pigeon chest, is a deformity of the chest characterized by a protrusion of the sternum and ribs. It is the opposite of pectus excavatum.
Causes
Pectus carinatum is an overgrowth of cartilage causing the sternum to protrude forward. It occurs in 3 different ways. The least common way is post surgically after open heart surgery. Sometimes the sternum does not heal flat and there is a protrusion of the sternum. The second most common is from birth. It is evident in newborns as a rounded chest and as they reach 2 or 3 years old the sternum begins to grow outwardly even more. The most common occurrence for pectus carinatum seems to be in the 11-14 year old pubertal male undergoing a growth spurt. Some parents report that their child's pectus seemingly popped up 'overnight'.
It may occur as a solitary congenital abnormality or in association with other genetic disorders or syndromes : Turner syndrome, Marfan syndrome, Ehlers Danlos Syndrome, Morquio syndrome, Noonan syndrome, Trisomy 18, Trisomy 21, homocystinuria, osteogenesis imperfecta, multiple lentigines syndrome, Sly syndrome and Scoliosis.
In about 25% of cases of pectus carinatum, the patient has a family member with the condition.
Epidemiology
Pectus deformities are common; about 1 in 400 people have a pectus disorder.[1]
Pectus carinatum is rarer than pectus excavatum, another pectus disorder, occurring in only about 20% of people with pectus deformities.[1] About four out of five patients are males.[2]
Symptoms
People with pectus carinatum usually develop normal hearts and lungs, but the deformity may prevent these from functioning optimally. In moderate to severe cases of pectus carinatum, the chest wall is rigidly held in an outward position. Thus, respirations are inefficient and the individual needs to use the accessory muscles for respiration, rather than normal chest muscles, during strenuous exercise. This negatively affects gas exchange and causes a decrease in stamina. Children with pectus deformities often tire sooner than their peers, due to shortness of breath and fatigue. Commonly concurrent is mild to moderate asthma.
Some children with pectus carinatum also have scoliosis (curvature of the spine). Some have mitral valve prolapse, a condition in which the heart mitral valve functions abnormally. Connective tissue disorders involving structural abnormalities of the major blood vessels and heart valves are also seen. Although rarely seen, some children have other connective tissue disorders, including arthritis, visual impairment and healing impairment.
Apart from the possible physiologic consequences, pectus deformities can have a significant psychologic impact. Some people, especially those with milder cases, live happily with pectus carinatum. For others, though, the shape of the chest can damage their self-image and confidence, possibly disrupting social connections and causing them to feel uncomfortable throughout adolescence and adulthood. As the child grows older, especially if male, bodybuilding techniques may be useful for balancing visual impact.
Prognosis
Pectus deformities usually become more severe during adolescent growth years and may worsen throughout adult life. The secondary effects, such as scoliosis and cardiovascular and pulmonary conditions, may worsen with advancing age.
Body building exercises (often attempted to cover the defect with pectoral muscles) will not alter the ribs and cartilage of the chest wall, and are generally considered not harmful.
Most insurance companies no longer consider chest wall deformities like pectus carinatum to be purely cosmetic conditions. While the psychologic impact of any deformity is real and must be addressed, the physiological concerns must take precedence. The possibility of lifelong cardiopulmonary difficulties is serious enough to warrant a visit to a thoracic surgeon.
Treatment
External bracing technique
In children, teenagers, and young adults who have pectus carinatum and are motivated to avoid surgery, the use of a customized chest-wall brace that applies direct pressure on the protruding area of the chest produces excellent outcomes. Willingness to wear the brace as required is essential for the success of this treatment approach. The brace works in much the same way as orthodontics (braces that correct the alignment of teeth). The brace consists of front and back compression plates that are anchored to aluminum bars. These bars are bound together by a tightening mechanism which varies from brace to brace. This device is easily hidden under clothing and must be worn from 14 to 24 hours a day. The wearing time varies with each brace manufacturer and the managing physicians protocol, which could be based on the severity of the carinatum deformity (mild moderate severe) and if it is symmetric or asymmetric.
Depending on the manufacturer and/or the patient's preference, the brace may be worn on the skin or it may be worn over a body 'sock' or sleeve called a Bracemate, specifically designed to be worn under braces. A physician or orthotist or brace manufacturer's representative can show how to check to see if the brace is in correct position on the chest.
Bracing is becoming more popular over surgery for pectus carinatum, mostly because it eliminates the risks that accompany surgery. The prescribing of bracing as a treatment for pectus carinatum has 'trickled down' from both paediatric and thoracic surgeons to the family physician and pediatricians again due to its lower risks and well-documented very high success results.
Regular supervision during the bracing period is required for optimal results. Adjustments may be needed to the brace as the child grows and the pectus improves.
If the person with PC is not treated with a brace by the end of puberty, the brace technique is not an option, as the shape of the ribcage and sternum are set for the rest of their lives.
Surgical
For patients with severe pectus carinatum, surgery may be necessary. However bracing could and may still be the first line of treatment. Some severe cases treated with bracing may result in just enough improvement that patient is happy with the outcome and may not want surgery afterwards.
If bracing should fail for whatever reason then surgery would be the next step. The two most common procedures are the Ravitch technique and the Reverse Nuss procedure.
The Nuss was developed by Donald Nuss at the Children's Hospital of the King's Daughters in Norfolk, Va. The Nuss is primarily used for Pectus Excavatum, but has recently been revised for use in some cases of PC, primarily when the deformity is symmetrical.
Other options
After adolescence, some men and women use bodybuilding as a means to hide their deformity. Some women find that their breasts, if large enough, serve the same purpose. Some plastic surgeons perform breast augmentation to disguise mild to moderate cases in women. Bodybuilding is suggested for people with symmetrical pectus carinatum.[3]
See also
References
- ↑ 1.0 1.1 "Pediatric Surgery | Mattel Children's Hospital UCLA - Los Angeles, CA". Surgery.ucla.edu. Retrieved 2011-08-31.
- ↑ "Pectus Carinatum, Cincinnati Children's Hospital Medical Center". Cincinnatichildrens.org. 2007-09-26. Retrieved 2011-08-31.
- ↑ carinatum.com, Pectus Carinatum Exercise.
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