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Crazed Vigilante
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Sounds like you may have a depressed sternum (AKA Funnel Chest). It can be fixed with cosmetic surgery. It can also be progressive and turn dangerous. I found a long (but very complete & informative) journal article on it:
Pectus excavatum - pathophysiology, clinical presentation, surgical repair
American Family Physician, July, 1992 by Hoyt W. Crump
Pectus excavatum, also known as funnel chest, is the most common congenital defect of the chest wall, accounting for 90 percent of all congenital chest wall defects (others include pectus carinatum, bifid sternum, Cantrell's syndrome and Poland's syndrome).[1-3] Until now, most family physicians, internists and pediatricians have regarded pectus excavatum as principally a cosmetic problem, and it is discussed as such in standard texts.[1,4-8] However, recent studies have shown that impairment of cardiac and respiratory function with associated exercise intolerance can result from the abnormal chest wall of pectus excavatum.[1,7-14] In addition, studies have shown improvement in cardiac and respiratory function and exercise tolerance after surgical repair.[1,9,12,15-17] Because the estimated incidence of pectus excavatum is between one in 127[3] and one in 167,[10] most family physicians will encounter several patients with this condition.
Pathophysiology
The underlying cause of pectus excavatum is unknown. Most authorities currently believe the condition is the result of an unbalanced overgrowth of the rib cartilages, which pushes the sternum inward.[1,3,7,18] The older theory implicating a short subxiphoid tendon (central tendon of the diaphragm) as the cause has been discounted.[7,8,10] It is now understood that the short subxiphoid tendon is the result, not the cause, of pectus excavatum.[1,8]
The sternal depression most commonly begins at the attachment of the third rib to the sternum, but occasionally it is noted at other positions.[9,15] The defect is usually present at birth but progression is variable.[8-10,15,19] In some relatively mild cases, the severity of the condition may worsen with the pubertal growth surge.[2,3,8-10] The ratio of boys to girls affected has been estimated to be between 2:1[9,10] and 3:1.[3,9] A familial distribution through a nonsexlinked gene has been suggested,[3] although some authorities believe the condition occurs in a sporadic fashion.[8-10,15]
A characteristic abnormal respiratory pattern may occur on exertion, causing retraction of the sternum and lateral movement of the chest wall.[1,8,15] Increased oxygen uptake during maximal exertion is thought to occur as a result of a greater expenditure of energy due to the abnormal chest architecture.[7,11,13] Decreased pulmonary and cardiac function on heavy exertion have been documented over the past 15 years in adolescents and adults with pectus excavatum and more recently in children with severe cases.[1,7-9,12,15,20]
The posterior displacement of the lower sternal segment moves the heart and middle mediastinal contents posteriorly and to the left, and creates a rotational effect in severe cases.[2,4,8,9,12,15,17] This causes cardiopulmonary dysfunction due to elevated right atrial pressure and impaired diastolic filling of the right atrium and ventricle,[8,9,15,20] resulting in decreased stroke volume and cardiac output during upright exercise.[20]
Many patients with pectus excavatum have heart murmurs and abnormal electrocardiograms, which may be due to the indentation of the heart and its lateral displacement and rotation. These abnormalities usually disappear postoperatively.[8,9,15,16]
Clinical Presentation
The depression of the sternum associated with pectus excavatum is usually noted at birth,[1,10,15] indicating that the condition originates in utero. Although reports of pectus excavatum appeared in the medical literature for hundreds of years,[1,15] Ravitch[14] published the first detailed description of pectus excavatum in 1949. He noted five characteristics: depressed sternum, rounded shoulders, slight dorsal kyphosis, prominent potbelly and abnormal retraction of the sternum on deep inspiration[1,14] Figures 1 and 2).
Pectus excavatum may occur in otherwise normal children or may be associated with minor congenital anomalies, such as pes planus and scoliosis. It may also occur in more severe forms as part of such conditions as Marfan's syndrome and certain cardiac defects.[3,8-10,15]
Infants and young children with this condition are often brought to the physician by their parents because of concern about the appearance of the chest. Since pectus excavatum diagnosed in the first year of life may improve or completely disappear without treatment in a significant number of cases, close observation is indicated. If improvement does not occur by age three, spontaneous remission is unlikely; it virtually never occurs after age six.[9,19]
Adolescents often have a rapid growth surge that accentuates the defect,[2,3,8-10] heightening concerns in this already emotionally vulnerable age group. Patients with pectus excavatum are often self-conscious; hence, many authorities recommend early repair, before the patient's peers are old enough to notice the defect.[2,3,7-10,15] Ages four to six, when the child is ready for a hospital experience, are frequently recommended as the optimal ages for surgical repair. However, in cases in which a relatively mild defect worsens during puberty, the defect may be surgically corrected at that time.[2,3,7-10,15] In a few cases, the defect has been corrected in adulthood.[7,10,12,15,17,21]
Common complaints from adolescents with pectus excavatum include shortness of breath on exertion and chest pain.[1,7,8,10,15,16,18] The connection between chest pain and pectus excavatum is sometimes overlooked in review articles about causes of chest pain in children.[22] Children with this condition often also have an increased frequency of respiratory infections.[3,18] Although a mild defect may not cause symptoms and may be compatible with a normal life expectancy, moderate to severe pectus excavatum is associated with increased physical symptoms and disability. [1,7,8,10,12,15,19] In one series,[19] 15 of 26 adults with pectus excavatum were found to have disabling psychologic symptoms.[19] Many authors who have had experience with a significant number of these patients have also noted the psychologic effects associated with pectus excavatum and the improvement of such symptoms following surgical correction.[8,10,15,19]
Diagnosis
The diagnosis of pectus excavatum is evident on inspection of the chest. The degree of severity may be determined by observation and confirmed by lateral chest films.[2,7,15] Selective computed tomographic (CT) scanning of the chest has been used experimentally in an attempt to identify patients most likely to benefit from corrective surgery.[2,23] It was postulated that the ratio of the transverse diameter to the narrowest anteroposterior diameter of the chest on CT could be helpful in deciding whether a young child should undergo operative repair. It was noted that patients with a ratio greater than 3.25 may experience moderate to severe changes with significant shifting of the heart and middle mediastinum into the left side of the thorax. Older methods of grading the severity of the defect, such as measuring the volume of water required to fill the defect or using obstetric calipers to measure the depth of the defect, are no longer commonly used.[2]
Indications for Surgical Repair
In addition to the cosmetic and psychologic benefits of surgical correction, many patients have improved exertion tolerance.[1,7-9,12,13,15,16] Using a standard exercise protocol, Peterson and colleagues[16] showed that of 13 patients with pectus excavatum, only four were able to reach target heart rates on exercise without symptoms such as dyspnea or severe fatigue. Postoperatively, nine of the same group of patients were able to reach the target heart rate without such symptoms.[16]
Most patients with preoperative chest pain note diminution or absence of pain after surgical correction of pectus excavatum.[1] Cardiac dysrhythmias and congestive heart failure have been alleviated by operative repair of the chest wall in a number of cases.[9,10,12,15,17] A number of cardiac surgeons have repaired pectus excavatum at the time of cardiac surgery to overcome technical problems of cardiac exposure.[21,24]
Mortality in large reported studies of surgical repair of pectus excavatum has ranged from zero to 0.5 percent [2,3,7,8,15]; most deaths have occurred in patients with multiple congenital defects.[7] Morbidity occurs in about 5 percent of cases or less and includes superficial wound infection or separation, pneumothorax, subcutaneous fluid collection, shift in substernal strut (if used) and pneumonitis.[3,7] Rarer sequelae, such as unilateral gynecomastia due to intercostal nerve damage, have been reported.[25] Use of blood transfusions has decreased to less than 1 percent of cases since the introduction of electrocautery 20 years ago.[2,15]
Large studies of patients who were followed for several years after corrective surgery indicate good or excellent results in 95 percent or more of patients.[2,3,7,15]
The Operation
Surgery for pectus excavatum is performed by pediatric and thoracic surgeons. Since Ochsner and De Bakey's report of the first modern operation for this condition in 1939,[1,19] at least 30 variations and modifications of surgical technique have been described.
Four general procedures are currently in use. In the most common procedure, the sternum is surgically moved from its depressed position and repositioned anteriorly by sternal osteotomy.[1-3,8,10,15,19] A second type of procedure also mobilizes the sternum and, after repositioning, uses external bracing to pull the sternum anteriorly; a metal wire is placed under the sternum at the time of operation and is pulled out to the brace through the chest wall.[7,15,19] This bracing is used for six weeks.[7]
The most recently developed procedure is known as sternal turnover. During this procedure (developed by Wada and colleagues in Japan), the entire deformed sternum is removed, turned over and then surgically stabilized.[1,15,24] Sternal turnover has been used in both infants and adults.[24] A fourth type of operation done for cosmetic reconstruction with no structural change of the thoracic wall uses a custom-made Silastic implant. This is appropriate only for adults and does not correct the underlying structural defect. 1, 26
Depending on the procedure utilized, the patient may be hospitalized for three to seven days.[7,15] Frequently, a chest protector made of a rigid plastic material and custom-molded to the patient's anterior chest wall is worn for six to eight weeks to protect the operative site from direct trauma 3 (Figure 3). The substernal strut (if used) is removed three to six months after the initial procedure[2,3,9] in a relatively brief operation, usually in an outpatient setting.
Illustrative Case
A 14-year-old boy presented with a complaint about the appearance of his chest. Mild pectus excavatum, present since birth, had worsened during the preceding 18 to 24 months as a result of the pubertal growth surge. His parents stated that he had become increasingly shy, withdrawn and depressed, requiring medication with a tricyclic antidepressant. Although a good athlete and very active, he had inappropriate dyspnea during vigorous exercise, such as when he would run farther than one-half of a mile. No history of increased respiratory infections or chest pain was present.
The physical examination was unremarkable except for the typical findings of moderate to marked pectus excavatum and bilateral pes planus. CT scan of the chest showed a 5:1 ratio of transverse diameter to narrowest anteroposterior diameter of the chest. Slight displacement of the heart to the left was noted.
The parents left the final decision about surgery up to the patient, who decided to have the operation. The procedure and postoperative course were uneventful except for fever attributed to atelectasis, and he was discharged six days after surgery (Figures 4 through 8).
Postoperatively, the patient's mood brightened markedly and the tricyclic antidepressant medication he had been on for several months was stopped, with no recurrence of depression. Nine weeks postoperatively, on his first attempt at running, he was able to run three-quarters of a mile without significant dyspnea. Three months postoperatively, the metal substernal strut used to stabilize the sternum migrated to the left subpectoral area and caused pain; the strut was removed in a brief outpatient procedure. Five months postoperatively, the excellent cosmetic results persisted (Figure 9).
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