Pectus excavatum, often referred to as funnel chest, is the most common congenital chest wall deformity, involving an inward depression of the sternum and rib cage. This condition affects the anterior thoracic wall, resulting from abnormal growth of the costal cartilages connecting the ribs to the breastbone. While many cases are mild and present primarily as a cosmetic difference, the severity exists on a broad spectrum. Determining where an individual’s condition falls is important for understanding when this structural difference moves from a visible anomaly to a medical concern affecting health and quality of life.
Understanding the Physical Manifestation
The physical characteristic of pectus excavatum is a caved-in or sunken appearance of the chest, ranging from a slight indentation to a deep concavity. Although present at birth, this deformity frequently becomes more pronounced during adolescent growth spurts as the skeletal structure rapidly changes. The visual presentation is classified by the depth of the sternal depression and whether the indentation is symmetrical. Mild cases show a shallow, barely noticeable depression causing no physical symptoms, while moderate cases present with a more visible indent, sometimes accompanied by a flaring of the lower ribs. The most severe cases feature a deep, pronounced depression that is often asymmetrical, visibly pushing the breastbone close to the spine.
Evaluating Cardiopulmonary Function
When the sternal depression is significant, the condition physically compromises the space available for the heart and lungs, transitioning from a cosmetic issue to a functional one. The depressed sternum can displace the heart to the left side, and in severe instances, cause direct compression of the heart’s right chambers. This compression impairs the heart’s ability to fill with blood efficiently, sometimes leading to symptoms like mitral valve prolapse or a fast heartbeat.
The restricted thoracic space also limits the maximum capacity of the lungs, resulting in restrictive lung disease. This limitation on lung expansion often manifests as shortness of breath (dyspnea) and chronic pain. Patients with functional impairment frequently report exercise intolerance, feeling fatigued or winded sooner than their peers during physical activity.
To objectively measure severity, physicians rely on a computed tomography (CT) scan of the chest. This scan allows for the calculation of the Haller Index, a widely used metric that divides the transverse diameter of the chest by the shortest distance between the sternum and the spine. A normal Haller Index is approximately 2.5, while an index greater than 3.25 is classified as severe and is often a threshold for surgical correction.
Assessing Quality of Life and Self-Image
Beyond the physical effects on heart and lung function, pectus excavatum can severely impact a patient’s psychological well-being and quality of life. The visible nature of the deformity, particularly during the vulnerable adolescent and young adult years, can lead to significant psychological distress. Patients frequently report low self-esteem and body image disturbance, even when their cardiopulmonary function is not physiologically impaired.
The appearance of the sunken chest can cause social anxiety, prompting individuals to avoid situations where their torso might be exposed. This leads to avoidance behaviors, such as withdrawing from sports, refusing to swim, or avoiding public changing rooms. For many patients, this psychological harm, which reduces engagement in daily life, is itself a sufficient reason to seek corrective treatment. Studies indicate a significant disturbance in body image among those with the condition compared to control groups.
Treatment Pathways for Correction
Treatment for pectus excavatum is determined by whether the primary concern is functional impairment, psychological distress, or a combination of both. Non-surgical management is a starting point, particularly for mild cases or younger patients with a flexible chest wall. Physical therapy can help improve posture, while the vacuum bell device offers a non-invasive option.
The vacuum bell is a suction cup placed on the chest that uses negative pressure to temporarily lift the sternum forward. Consistent use over many months may lead to a permanent change, working best in pre-adolescent children whose cartilage is more pliable. However, for moderate to severe cases, or when cardiopulmonary function is compromised, surgical correction is the definitive solution.
The two main surgical approaches are the minimally invasive Nuss procedure and the open Ravitch procedure. The Nuss procedure involves inserting a curved metal bar behind the sternum to push it outward, which is then removed after two to four years. Conversely, the Ravitch procedure is an open surgery that involves the removal of the deformed cartilage before the sternum is repositioned and stabilized with temporary supports. The Nuss procedure is generally preferred for its minimally invasive nature and shorter operative time. However, the Ravitch procedure may be chosen for older patients or those with highly asymmetrical or recurrent deformities.