Pectus Excavatum is the name for a dent in the center of the chest. This is the most common congenital chest wall deformity, meaning it is present from birth, and it accounts for the vast majority of all chest wall anomalies. Although the sight of a sunken chest can be alarming, its severity varies greatly among individuals, ranging from purely cosmetic to physically restrictive. It occurs more frequently in males than in females, with an estimated prevalence of about 1 in 300 to 1,000 live births. Pectus Excavatum, or “chest hollow” in Latin, often becomes more noticeable during periods of rapid growth, such as the adolescent growth spurt.
Naming the Condition and Physical Features
Pectus Excavatum is commonly referred to as “funnel chest” or “sunken chest” due to its visual appearance. The condition is characterized by an inward growth of the sternum (breastbone) and the adjacent costal cartilages, which attach the ribs to the sternum. This inward depression typically involves the lower part of the sternum and the ribs from the third to the seventh levels.
The depression can be classified as either symmetrical or asymmetrical. A symmetrical deformity involves a uniform, central dip in the chest. An asymmetrical one, which is more common, shows the sternum rotated or depressed more heavily on one side. The severity of the inward curve is quantified using the Haller Index, a measurement derived from cross-sectional imaging like a CT scan.
The Haller Index is calculated by dividing the maximum inner width of the chest by the distance between the back of the sternum and the front of the spine at the point of maximum depression. A normal chest has a Haller Index of around 2.5 or less. An index of 3.25 or higher is generally accepted as the threshold for a moderate or severe deformity and often serves as a key indicator for considering surgical correction. This objective measurement helps clinicians determine the degree to which the internal organs may be compressed.
Underlying Causes and Development
The precise cause of Pectus Excavatum is unknown, and most cases are considered idiopathic. However, the structural mechanism involves the abnormal growth and development of the costal cartilage. Excessive growth of this cartilage pushes the sternum backward and into the chest cavity, creating the characteristic funnel shape.
A strong genetic component is involved, as a positive family history exists in up to 40% of cases, suggesting a hereditary link. The condition is often an isolated finding, but it can occur in conjunction with certain connective tissue disorders. These associated syndromes, such as Marfan syndrome or Ehlers-Danlos syndrome, involve issues with the body’s connective tissues, supporting the theory of a cartilage growth abnormality.
Physical and Psychological Impact
While many mild cases are purely cosmetic, moderate to severe Pectus Excavatum can lead to functional consequences by physically reducing the space available for the heart and lungs. The inward sternum can compress the heart, potentially displacing it toward the left side of the chest. This mechanical pressure may cause symptoms such as heart palpitations, an irregular heartbeat, or a heart murmur.
The compression also restricts the full expansion of the lungs, especially during physical exertion. Individuals with more pronounced indentations often report easy fatigue, shortness of breath, and a reduced tolerance for exercise. They may experience chest pain or discomfort, which is a result of the abnormal mechanics of the chest wall.
Beyond the physical limitations, the condition can have a significant psychological toll, particularly during adolescence. The visible difference in chest shape frequently leads to body image issues, self-consciousness, and low self-esteem. Teenagers may avoid activities that require them to expose their chest, such as swimming or using changing rooms, which can result in social anxiety and withdrawal.
Management and Treatment Options
Management depends on the severity of the deformity and the presence of functional symptoms. For mild cases that are primarily cosmetic and do not impact heart or lung function, non-surgical approaches are recommended. These may include physical therapy to improve posture and general fitness, which can sometimes make the condition less noticeable.
Another non-surgical option is the use of a Vacuum Bell device. This is a suction cup placed on the chest wall that attempts to pull the sternum forward over time. The device is worn daily for a specific duration, often over many months or years, and is used for younger patients or those with mild to moderate, flexible defects.
For more severe cases, surgical correction is necessary to relieve pressure on the internal organs and improve the chest’s appearance. There are two main surgical techniques used to repair the condition: the Nuss procedure and the Ravitch procedure.
The minimally invasive Nuss procedure involves inserting a curved metal bar through small incisions on the sides of the chest. The bar is then rotated to push the sternum outward, where it remains for several years before being removed in a second procedure. The open repair, known as the Ravitch procedure, is a more traditional technique that involves surgically removing the abnormally grown costal cartilage to allow the sternum to be repositioned and stabilized.