What is Pectus Carinatum (Pigeon Breast) ?
It is the second most common chest wall disorder following Pectus excavatum (Funnel chest). It is the abnormal growth of the rib cartilage between rib and sternum (breastbone). It appears as swelling/protrusion on the chest wall. In general, it includes costal cartilages on the bottom part of the sternum. Although symmetrical (two-sided) in some cases, it mostly develops asymmetrically (one-sided). As in Pectus excavatum, bad posture (posture disorder) is noticeable. This abnormal growth of the cartilage usually occurs between 11-15 years of age during adolescence period. Pectus carinatum also occurs three times more often in men than women. Pigeon breast comprises of 5% to %20 of chest wall deformities. It occurs in one in every 1000-2500 live births.
Pectus Carinatum Sample
Pectus Carinatum Sample
Etiology
There are assumptions that abnormalities developed during cartilage development as in Pectus excavatum may cause the disease. Abnormal growth of the costal cartilages leads to protrusion. However, main cause of this abnormal growth is not known exactly. Family history and the presence of other accompanying diseases also suggest an abnormality in the development of connective tissue. Among other theories, there is abnormal diaphragm development and growth of costal cartilages in volume. Some other theories include abnormal diaphragm development and volume growth of costal cartilages. Pectus carinatum usually occurs between 11-15 years of age, childhood and adolescence period. It rarely can be detected immediately after birth. Almost half of the patients realize the disease during adolescence period where growth starts.
Signs
Similar to Excavatum, atypical chest pain and shortness of breath developing with exercise is remarkable. When lying face down position, chest pain and sensitivity are seen frequently. Interestingly, asthma-like symptoms are identified in almost one fourth of young patient group. As in Excavatum, abnormal chest wall appearance psychologically affects the patient in a negative way. Lack of self-confidence, particularly negative psychological effects due to physical appearance may be seen in patients.
No significant relationship indicating that Pectus carinatum leads to a decrease in lung or heart functions could be determined. In some publications, it was reported that more lung complaints were observed in carinatum compared to excavatum. Shortness of breath, tachypnea, emphysema developed over time due to reduced lung capacity (lung tissue damage) and infection (e.g. pneumonia) may develop. However, further investigation is needed to show that the syndrome increases the shortness of breath by effort.
In some scientific studies congenital heart disease has been reported in children with carinatum who has early closure of the sternal sutures. Although Pectus carinatum does not cause important complaint, it may lead to cardiac rhythm problem and decrease in contraction of the cardiac muscle. In long term, it may lead to decrease in the respiratory capacity, shortness of breath, rapid breathing and inflammation in the lungs by blocking enlargement of the lungs due to hardness of the rib cage. Moreover, depending on the severity of the structure disorder, patient may complain about sensitivity in this body part as a result of bumping protruded areas frequently.
In contrast to Pectus excavatum, location of the heart is not affected. On the other hand, a relationship indicating that incidence of mitral valve prolapse is high in patients with pigeon breast has been determined.
Diagnosis
“Clinical findings” are adequate for physicians for the diagnosis of Pectus carinatum. In other words, most of the time, physical examination of patient, listening of his/her complaints and determination of the chest wall disorder would be adequate for diagnosis. There is no specific blood test as in pectus excavatum, however, severity of pectus carinatum can be determined by radiological evaluation. Furthermore, other associated problems of the spine such as scoliosis may be determined. The most useful imaging method that allows evaluation of the severity of pectus carinatum in a more precise manner and that should be taken into account considering surgical correction is the computed tomography. Magnetic resonance (MR) is also an alternative imaging method that prevents receiving radiation and that may particularly be preferred in pediatric patients.
Unlike those methods, a device, which is one of clinical measurements used in the evaluation of the shape of the protrusion on the chest wall and of the severity of the disease and facilitates determination of the most appropriate treatment method for physicians, is very useful during the diagnosis. With this pressure machine developed by Prof. Dr. Mustafa Yuksel, the pressure needed to apply for correcting the deformity on the chest wall is measured. This examination is very simple. While the patient stands leaning against wall, physician presses on the deformity with this device and at the time correction is seen, reads the pressure appeared on the screen of the device. If the pressure read in kg is less than 10 kg orthesis is planned; if it is between 10-14 kg, the condition is followed-up by pre- operative orthesis and if no improvement is achieved, surgery is planned; for the pressures above 14 kg, surgical treatment is planned.
More than one fourth of patients with Pectus carinatum, a history of chest wall disorder in their families is encountered. Sideways curvature (scoliosis) is detected in one fifth of patients. In 12% of patients, history of scoliosis is present in their families. As in Pectus excavatum, “Marfan syndrome” (connective tissue disease) should be suspected in patients with scoliosis and severe structural disorder. Rarely, “Morquio syndrome” or excessive inwards curvature of the lumbar (lower) spine (Hyperlordosis) and haunching of the back (kyphosis) may be seen.
Treatment
Severity of the disease determines the treatment. There are both orthesis and surgical treatment options. Orthesis method can be preferred in above mentioned mild cases, since it requires no surgical intervention. The principle of the orthesis is to provide anatomical correction by applying an external pressure with the aid of orthesis.
Orthesis - Non-surgical Method
Since the orthosis method does not require surgical intervention, it can be preferred in the mild cases mentioned above. The principle of orthosis is to provide anatomical correction by applying external pressure to the protruding area with the help of an orthosis.
It is especially effective in patients under the age of 17. After the necessary examination, if the patient is suitable for orthosis application, successful results are achieved.
You can find Pectus Carinatum Orthesis Treatment details here
Abramson Technique
Closed surgical method, the Abramson technique is similar to the Nuss technique utilized in Pectus excavatum. The difference is that the bar used in the surgery corrects the protrusion on the breastbone by pressing inwards. In order to correct the protrusion on the chest wall, a steel bar made from nickel-chromium alloy (or titanium bar custom made for those patients with allergy) is placed under the muscles endoscopically by closed surgery. Protruded anterior chest wall is pressed until anterior chest wall is brought to its normal position and then the bar is fixed.
After Dr.Donald Nuss developed the minimally invasive technique which has been successfully used in correcting pectus excavatum deformity in 1998, a need for a minimally invasive correcting method for patients with pectus carinatum arose. Dr. Horacio Abramson, an Argentinean thoracic surgeon, became the first scientist who modified the Nuss technique and applied it to patients with pectus carinatum and announced his successful outcomes to the world. Prof. Dr. Mustafa Yuksel has also been applying Abramson technique to his patients since 2006.
Ravitch Technique
In surgical treatment, sternum chondroplasty (open surgery) or a closed method, Abramson technique are the best options in correcting this deformity. Open surgery is the “Ravitch” technique which is also used in Pectus excavatum.