CASE 1678 Published on 29.09.2002

Pectus excavatum

Section

Chest imaging

Case Type

Clinical Cases

Authors

H J Williams, A H S Ahmed, R C Bhatt

Patient

34 years, female

Categories

No Area of Interest ; Imaging Technique Digital radiography

No Procedure ; No Special Focus ;

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Clinical History

This patient was referred by her GP for a chest X-ray because of persistent cough and wheeze.

Imaging Findings

This patient was referred for a chest X-ray because of persistent cough and wheeze. The clinical diagnosis was asthma, but her GP wanted to exclude other causes. An abnormality was seen on her PA chest radiograph and she was recalled for a lateral view to be taken.

Discussion

This patient has a chest wall deformity with a depressed sternum known as pectus excavatum or "funnel chest". This deformity is quite common, and patients are almost always asymptomatic, but it does cause radiographic abnormalities that can be mistaken for pathology.

In patients with pectus excavatum the heart is displaced dorsally and often "squeezed" between the depressed sternum and the spine. This causes the cardiac silhouette to be shifted to the left and can give the impression of cardiomegaly. The left heart border becomes straightened as a result, and the main pulmonary trunk can look enlarged.

The right heart border may bulge to the right if the heart is compressed against the spine, but is usually displaced to the left. Ill-defined shadowing in the right cardio-phrenic angle gives the impression of right middle lobe pathology, but does not show an air bronchogram. Its cause is the tissues of the anterior chest wall projected over the lung adjacent to the right heart.

Clues as to the presence of pectus excavatum on the PA radiograph are the easy visibility of the thoracic vertebral bodies and inter-vertebral discs through the heart shadow (as the heart is displaced to the left) and horizontal posterior ribs with downward sloping anterior ribs (giving a "7" and "reverse-7" configuration). Clinical examination of the patient will confirm the presence of a depressed sternum. A lateral radiograph demonstrates the sternal depression, which varies from minor sternal flattening causing slight reduction in the AP diameter of the chest to marked sternal depression and compression of the heart against the spine. The lateral radiograph also confirms the absence of right middle lobe disease and cardiomegaly.

Rarely pectus excavatum is associated with mitral valve prolapse and patients with Marfan's syndrome may have pectus excavatum.

Differential Diagnosis List

Pectus excavatum

Final Diagnosis

Pectus excavatum

References

[1] Raphael MJ, Donaldson RM. The normal heart: methods of examination (Volume 1, Chapter 21). In Sutton D (Ed) A Textbook of Radiology and Imaging, Sixth Edition. Churchill Livingstone, New York, pp 541-66 (1998).

[2] Meholic A, Ketai L, Lofgren R. Chest Wall (Chapter 14). In Fundamentals of Chest Radiology. WB Saunders Company, Philadelphia, pp 221-34 (1996).

Case information

URL:	https://www.eurorad.org/case/1678
DOI:	10.1594/EURORAD/CASE.1678
ISSN:	1563-4086

Figure 1

Postero-anterior and lateral chest x-rays

PA chest radiograph showing an indistinct right heart border and ill-defined opacity in the right cardio-phrenic angle. There is however no air-bronchogram to indicate consolidation, and no volume loss in the right lung signifying collapse.

Lateral chest radiograph confirming a depressed sternum or pectus excavatum which is the cause of the apparent abnormality on the frontal radiograph.

Figure 2

A second patient with pectus excavatum

The PA radiograph shows a slight shift of the mediastinum to the left with a straight left heart border and blurring of the right heart border with increased opacity adjacent to the right of the vertebral column. Note the increased downward inclination of the anterior ribs.