Funnel chest (funnelchest) is a congenital and often familial condition. It is more common in males than females, with a reported male to female ratio of 4:1, and is a dominant trait. The incidence of funnelchest is 2.5 per 1,000 in those with a family history, while in those without a family history, the incidence is only 1.0 per 1,000.
Funnel chest is a progressive disease, with the sternal depression becoming more pronounced with age. The external appearance is characterized by a sunken anterior chest, anterior shoulder extension, a slight hunchback and a prominent epigastrium.
Signs and symptoms.
The sternal body (especially the root of the glabella) and its corresponding 3rd to 6th ribs are sunken inward, resulting in a funnel-like anterior chest wall, with the heart displaced by the pressure and the lungs limited by the thoracic deformity, which affects the child’s cardiopulmonary function. The child has palpitations and shortness of breath after activity, and often develops upper respiratory tract and lung infections and even heart failure. The symptoms become more obvious after the age of 3, with concave chest, convex belly, emaciation and poor growth.
In infancy, the symptoms of compression of funnel chest are often unnoticed. Children are often thin, immobile, prone to upper respiratory tract infections, and have limited mobility. Exertional expiratory volume and maximum ventilation volume are significantly reduced. The child may experience panic, shortness of breath and dyspnea during activity. In addition to the thoracic deformity, there are often special body shapes such as mild hunchback and abdominal protrusion. The funnel chest deformity compresses the heart and lungs, and the heart is mostly displaced to the left side of the chest. The deformity tends to be symmetrical in younger patients with funnel chest and gradually becomes asymmetrical with age, with a familial tendency or with congenital heart disease.
Mild funnel chests can be asymptomatic, while more severe deformities compress the heart and lungs, affecting respiratory and circulatory function, reducing lung capacity, increasing functional residual air volume, and reducing activity tolerance. Young children often have recurrent respiratory infections with cough and fever and are often diagnosed with bronchitis or bronchial wheeze. Young children have fewer circulatory symptoms, while older ones can present with dyspnea, rapid pulse, palpitations, and even pain in the precordial region after activity, mainly because the heart is compressed, cardiac blood output cannot meet the needs during exercise, and the myocardium is hypoxic, thus causing pain. Some patients may also have arrhythmias and systolic murmurs.
Surgical indications.
Progressive worsening of symmetric funnel chest, Haller CT index ≥ 3.25 and/or funnel chest leading to respiratory symptoms, abnormal cardiopulmonary function.
Surgical methods.
1.Traditional method: modified Ravitch surgery, i.e., removal of bilateral rib cartilage, which is highly traumatic, has long recovery time and is prone to recurrence after surgery.
2.Nuss procedure: A tailor-made metal plate (PectusBar) is implanted under thoracoscopic guidance to push the sternal depression outward for corrective surgery. The metal plate is left in place for at least 2 to 5 years before being removed.
This procedure is less invasive, has a quick recovery, early bedtime, few postoperative complications, high satisfaction rate of deformity correction, and low recurrence rate. Good results are also obtained in adults. In addition to improving cardiopulmonary function, it can also correct the position of the sternum and ribs, and can take into account the aesthetic appearance, especially important for girls.
Postoperative complications of Nuss.
Recent complications.
1. Perioperative pericardial tamponade: During the placement of the metal plate in the funnel chest, it enters the pericardium, thus causing heart rupture and pericardial tamponade. This complication is very urgent and requires immediate subxiphoid incision for pericardial rupture repair or extracorporeal circulation for cardiac rupture repair if necessary. To prevent this complication, a retractor should be placed against the posterior wall of the sternum to enter the contralateral thoracic cavity under thoracoscopic guidance, avoiding the pericardium and large blood vessels.
2. Postoperative pain: Because the metal plate is placed to lift the sternum and rib cartilage, thus playing a role in thoracic contouring, the intercostal nerves are stretched and edematous, causing postoperative pain, especially in older children. The pain is usually relieved after 3 days and the patient can walk on his own, but in a few patients, the pain persists for 1 month or even 6 months after surgery. For older children with severe pain, an intravenous pain pump can be used. At the same time, older children should be encouraged to carry out routine activities, communicate well with the child, and forbid fixing a certain posture.
3.Postoperative pulmonary atelectasis: the child’s lung compliance changes, prolonged lying down or the child’s sputum is not effectively coughed up, thus causing sputum to block the bronchi, which eventually leads to pulmonary atelectasis. The child presents with fever, shortness of breath and even dyspnea, increasing the length of hospital stay. After surgery, the child should be encouraged to turn or sit as early as possible on the basis of being able to tolerate pain, so that the child can cough up more sputum, and routine nebulized inhalation for 48h after surgery, and aspiration if necessary.
4.Postoperative gastric ulcer: 24h~48h after surgery, pain under the saber, abdominal distension, vomiting and other symptoms, gastrointestinal decompression can drain a lot of coffee-like liquid, consider postoperative stress ulcer. Children with stress ulcers need to fast, while gastrointestinal decompression, intravenous application of acidophilus, generally 2 days after the symptoms relief.
5.Postoperative pleural effusion: because the child does not need to place a chest drain after surgery, delayed bleeding leads to pleural effusion, resulting in symptoms such as low fever and chest pain in the child, postoperative chest elevation films need to be reviewed, and if necessary, thoracic atresia drainage.
6.Postoperative sternal depression still exists: Consider that the area of sternal depression is large or the metal plate is not placed in the best position, 2 metal plates need to be placed or the position of the metal plate needs to be readjusted.
Long-term complications.
1, metal plate displacement: postoperative metal plate displacement caused by a variety of factors: (1) poor placement of metal plate or unsatisfactory orthopedic, small force area, easy to slip off; (2) improper fixation of metal plate, especially poor contact between fixator and chest wall, large mobility; (3) frequent postoperative activities of the child, especially vertical movement. The displacement of the metal plate usually occurs within six months after surgery, and a review of the chest film shows that the metal plate is obviously displaced and the external shape is obviously deformed. The displaced metal plate needs to be treated surgically again by removing the original metal plate and repositioning it in a fixed position. Communicate with the child’s family to limit the child’s frequent activities.
2. Allergic reaction to the incision and infection of the incision: many children have redness and swelling at the incision, skin rupture, protrusion of the fixator from the skin, and even pus flowing from the incision and generalized fever within 3 months to 2 years after surgery. If the redness and swelling at the incision is not obviously traumatic, it is considered to be an allergic reaction to the incision, and if it cannot be controlled, it is easy to cause infection and pus at the incision. If the child has an allergic reaction to the incision in less than 2 years, the incision needs to be changed for a long time to prevent infection of the incision, and the metal plate will be removed in 2 years, and the incision will heal after the metal plate is removed. If the incision is infected before 2 years, it is recommended to remove the metal plate as soon as possible, at the earliest 1.5 years after surgery, to prevent systemic symptoms.
3, scoliosis: older children with a strong sense of pain, long-term fixed a certain posture, resulting in children with scoliosis, that is, idiopathic scoliosis, generally in the postoperative six months more common. Scoliosis occurs in children, after communication with the child, if the posture can be adjusted, scoliosis can be improved, such as children with severe scoliosis, it is necessary to remove the metal plate, after the normal shape of the spine again placed in the metal plate.