Carinatum (Pigeon Breast)
It is the second most common chest wall disorder after Pectus excavatum (shoemaker's chest) in chest wall deformities. It is an abnormal growth in the cartilage of the rib between the rib and the sternum (Decapitation board). It manifests itself as a bulge / dislocation in the chest wall. It usually involves the costal cartilages in the lower part of the sternum. In some cases, it develops symmetrically (bilateral), but often asymmetrically (one-sided).
As with pectus excavatum, poor posture (posture disorder) also attracts attention. This abnormal growth in cartilage usually Decays during puberty, between the ages of 11 and 15. Pectus carinatum is also three times more common in men than in women. Pigeon chest accounts for 5 to 20 percent of chest wall deformities. It occurs in one of every thousand-2 thousand 500 live births.
It's reason
There are theses that abnormalities in the development of cartilage, such as in pectus excavatum, can cause this disease. In this case, the abnormal growth of the cartilaginous ribs leads to outward dislocation. However, the actual cause of this abnormal growth is not exactly known. Family history, the presence of other concomitant diseases suggest an abnormality in the development of connective tissue.
Some other theories, on the other hand, include abnormal diaphragm development and the Decubitus cartilage growing in volume. Pectus Decarinatum usually occurs in the period from 11 to 15 years, in childhood and adolescence. Rarely, it can also be detected immediately after birth. Almost half of the patients notice the disease in adolescence, when growth begins.
Symptoms
Similar to Excavatum, typical chest pain and shortness of breath that occur with exertion or exercise are noted. Chest pain and tenderness often occur when lying in a prone position. Interestingly, 'asthma'-like symptoms are described in about a quarter of the young patient group. Again, as with excavatum, the appearance of an abnormal chest wall negatively affects the patient psychologically. Lack of self-confidence in the patient, especially in adolescence, negative psychological effects caused by his physical appearance may be observed.
An obvious association that pectus carinatum leads to a decrease in lung or heart function has not been fully established. In some publications, it has been reported that more lung complaints are observed in the carinatum than in the excavatum. Shortness of breath, rapid breathing, emphysema (destruction of lung tissue) and infection (pneumonia, etc. over time due to a decrease in lung capacity.) formative. However, more research is still needed on the fact that it increases shortness of breath with exertion in some patients.
In some scientific studies, congenital heart disease has been reported in one fifth of children with carinatum who have premature closure of the sternum. Pectus carinatum, although it does not cause significant complaints in most patients, can lead to a rhythm problem in the heart and a decrease in the contraction of the heart November. In the long term, due to stiffness in the rib cage, it can prevent the lungs from expanding sufficiently, causing a decrease in respiratory capacity, shortness of breath, rapid breathing, and inflammation in the lungs. In addition, depending on the severity of the structural disorder, patients may complain of sensitivity in this area as a result of frequent bumps on the protruding areas of the chest.
Unlike pectus excavatum, the position of the heart is not affected in the carinatum. However, an association has been found that the incidence of mitral valve prolapse is higher in patients with pigeon breast.
Diagnosis
In the diagnosis of pectus carinatum, too, “clinical manifestations” are sufficient for doctors. In other words, a physical examination of the patient, listening to his complaints and detecting a disorder in the chest wall will often be sufficient for diagnosis. As with pectus excavatum, there is no specific blood test, but the severity of pectus carinatum can be determined by radiological evaluation. In addition, other related problems such as scoliosis in the spine can also be detected. Here are the most useful imaging method allows a more precise evaluation of the severity of surgical correction of pectus karinatum that should be taken into account when considering CT. Magnetic Resonance Imaging (MRI) is also an alternative imaging method that can be preferred, especially in pediatric patients, to prevent the patient from receiving radiation.
In contrast to these, a device that is one of the clinical measurements used to assess the shape of the dislocation in the chest wall and the severity of the disease, which makes it very easy for doctors to determine the most appropriate form of treatment, is also very helpful during diagnosis. Prof. Dr. With this pressure measuring instrument (pres sure machine) developed by Mustafa Yuksel, the pressure that needs to be applied to correct the deformity in the chest wall is measured. This examination is very simple. The doctor presses on the deformity with this tool while the patient is standing, leaning against the wall, and reads the pressure that appears on the instrument's screen in case of improvement. If the pressure read in kilograms is below 10 kilograms, orthotic treatment is planned, if it is between 10-14 kg, surgery is planned to be followed up with an orthosis before surgery, if there is no improvement, surgical treatment is planned to install a bar directly if the pressure is above Dec 14 kg.
A quarter of pectus carinatum patients also have a family history of chest wall disorders. In a fifth of patients, lateral curvature of the spine (scoliosis) is detected. 12 Percent have a family history of scoliosis. As with pectus excavatum, “Marfan syndrome” (connective tissue disease) should be suspected in patients with scoliosis or severe structural impairment in the carinatum. Rarely, “Morquio syndrome" or an extremely inward curvature (hyperlordosis) and hunchback (kyphosis) can be observed in the lower part of the spine, at the waist.
Treatment
The severity of the disease determines the treatment. There are both orthotic and surgical treatment options. The orthosis method may be preferred in the mild cases mentioned above due to the fact that it does not require surgical intervention. The principle of orthosis is to provide anatomical correction by applying pressure from the outside with the help of orthosis to the area that is dislocated outwards.
In surgical treatment, sternum chondroplasty (open surgery) or Abramson technique, which is a closed method, are the best options used to correct this deformity. Open surgery is the “Ravitch” technique, which is also used in Pectus excavatum.
The Abramson technique, which is a closed surgical method, is similar to the Nuss technique used in Pectus excavatum. The difference here is that the bar used in the operation corrects the protrusion on the faith board by pressing inward. With closed surgery to correct the protrusion in the chest wall, a steel bar with a nickel-chromium mixture (or a November titanium bar specially manufactured for allergy sufferers) is placed endoscopically under the patient's skin under the muscles. The protruding anterior chest wall is pressed back and the bar is fixed by bringing the anterior chest wall to the normal position.
Dr. After Donald Nuss developed his minimally invasive technique, which was successfully applied in the correction of pectus excavatum deformity in 1998, the lack of a minimally invasive correction method also began to be felt for patients with pectus carinatum deformity. Argentine breast surgeon Dr. Horacio Abramson modified the Nuss technique and became the first scientist to apply it to pectus carinatum patients and announce its successful results to the world at scientific meetings. Prof. Dr. Mustafa Yüksel has been applying the Abramson technique to his patients since 2006.
In the Abramson technique, the procedure briefly proceeds as follows:
In this technique, the chest cavity is not penetrated. Similar to those in the Nuss technique, but some with different features nickel – steel alloy, a metal bar, the appropriate shape after forming, tube trokarli thorax and passes through a tunnel that is created under the skin with the help of the projection at the most obvious level, apply pressure on the sternum and kostalar identified with steel wires on both sides of the stabilizer is attached to. these bars and stabilizers, which are kept in place for 2-4 years, are removed again under general anesthesia at the end of the specified period. Successful results are obtained in pectus carinatum cases with this technique, which has similarities with Nuss surgery in general characteristics. Patients stay in the hospital for an average of 4-5 days after surgery. In this process, only the cessation of pain is helped. You don't need anything else. The discharged patient may need family support at home for another 2-3 weeks. A person considering such an operation should be able to afford to stay away from school or work for 1-1.5 months. No recurrence of the deformity of the patients was observed after the removal of the bar.