Pectus excavatum

Clinical History

Routine pre-employment chest radiograph.

Imaging Findings

The patient was having a routine pre-employment medical check-up and a chest radiograph was ordered. The plain radiograph PA view showed sloping anterior ends of the ribs with an apparent shift of the heart towards the left side. These and other findings raised the possibility of a pectus excavatum deformity. A lateral view was performed to confirm the diagnosis.

Discussion

Pectus excavatum (funnel chest, depressed sternum) is a condition where the lower half of the sternum is depressed back and there is decreased distance in relation to the dorsal spine. It can occur as an isolated feature or associated with Marfan's syndrome or congenital heart disease especially atrial septal disease. Other syndromes associated with pectus deformity include Ehlers-Danlos syndrome,Fetal alcohol syndrome,homocystinuria and Noonan syndrome.The condition itself can cause a functional systolic murmur.Patient may present with chest pain,easy fatigability,dyspnea on exertion,palpitations and symptoms of restrictive lung disease(tracheal or bronchial compression). It is speculated that the abnormality is probably due to excessive growth of the lowermost cartilages.

Plain films on a PA view show a variety of findings including steep downward slope of the anterior ends of the ribs and a good delineation of the lower dorsal spine through the heart. There is a shift of the heart to the left with apparent cardiomegaly, straightening of the left heart border, and prominence of the main pulmonary artery; there is loss of the descending aortic interface. The right heart border is ill-defined, simulating right middle lobe consolidation. There may be a reduction of space occupied by the left lung. The lateral view of the chest will depict the extent of the depression of the sternum. A pectus index is sometimes used to assess the necessity for surgery. It is derived by dividing the transverse diameter of the chest by the anteroposterior diameter (Haller et al.). The normal value is 2.56 and a figure of more than 3.25 indicates that surgery is necessary.

Patients are usually asymptomatic and in severe cases various surgical procedures(Ravitich,Nuss procedure) have been described. CT or MR best quantify the severity and imaging of the anatomy in severe deformity.CT or MR is useful when surgery is contemplated or in evaluation of complications of surgical repair.

Differential Diagnosis List

Final Diagnosis

Pectus excavatum

URL:	https://www.eurorad.org/case/1801
DOI:	10.1594/EURORAD/CASE.1801
ISSN:	1563-4086