What is pectus excavatum? A chest wall deformity in which the breastbone (sternum) caves in, creating a concave chest. The deformity, also known as "funnel chest," can occur in both children and adults and may range from mild to severe. Mild forms are cosmetic only, but severe forms affect breathing, exercise capacity, and even heart function.

This article provides clear-cut answers to the most common questions about pectus excavatum, including its causes, symptoms, hereditary characteristics, and treatment options.

Normal Chest vs. Pectus Excavatum

To have a better idea of what pectus excavatum is, it is useful to observe a normal chest and compare it with one afflicted by this deformity.

Normal Chest:

• Flat or moderately curved sternum

• Symmetrical rib cage

• Normal breathing expansion

Pectus Excavatum:

• Visible inward indentation on the sternum and its adjacent ribs

• Asymmetry in some cases, where one is deeper than the other

• Possible heart and lung compression in severe cases

Morphological Features of Pectus Excavatum:

• The severity of depression varies from mild to extreme

• Usually increases in prominence throughout growth spurts

• May affect posture, leading to hunched shoulders and slouching

Learn more professional knowledge: Six Major Types of Pectus Excavatum

Is Pectus Excavatum Genetic?

Undoubtedly, the most frequent question is: What causes pectus excavatum? Genetics has been suspected by studies. A considerable proportion of patients report a family history of chest wall abnormalities, such as pectus excavatum or pectus carinatum. 

The genes involved have not yet been fully identified, but studies have shown that children face a higher risk if one of their parents has the disease. Having an awareness of this genetic susceptibility helps with early identification and timely evaluation.

Developmental and environmental factors can also be contributing factors, so genetics is only half the story.

What Are the Symptoms of Pectus Excavatum?

Symptom severity varies depending on how deeply the sternum is sunken. 

Common Pectus Excavatum Symptoms:

• Shortness of breath with activity

• Reduced endurance or a tendency to tire easily

• Intermittent chest pain

• Palpitations or tachycardia in severe cases

• A loss of appetite

• Indigestion

• Delayed growth

• Frequent upper respiratory infection

• Visible cosmetic problem affecting self-esteem

In mild cases, symptoms may be absent, with the condition affecting only the chest appearance. However, in moderate to severe cases, compression of the lungs and heart will limit physical activity, ultimately affecting the patients’ work and life.

Does Pectus Excavatum Get Worse with Age?

This query is repeatedly posed by parents: Does pectus excavatum worsen with age?

Yes. Pectus excavatum also becomes more noticeable during periods of rapid growth, especially in adolescence. During adulthood, while the form tends to stabilize, symptoms can worsen if the depression is deep enough to compromise cardiopulmonary function. Growth with time can also cause poor posture and scoliosis. Thus, early assessment and treatment of pectus excavatum are vital, particularly in children and adolescents.

Pectus Excavatum Diagnosis and Evaluation

Early and correct pectus excavatum diagnosis is necessary to define the extent of the condition as mild, moderate, or severe, and to guide the best pectus excavatum treatment. While the sunken appearance of the chest is obvious on physical exam, the extent of internal impact on the heart and lungs must be accurately determined.

A combination of functional tests, imaging tests, and clinical exams is used by doctors to prepare an integrated report.

1. Physical Examination

The first step is a comprehensive physical examination conducted by a healthcare professional. The healthcare professional, under this test, measures the depth of the depression of the chest and examines the symmetry of the rib cage. While visual inspection provides valuable cues, it falls short of assessing the internal organ involvement.

2. Imaging Exams

Imaging is a diagnostic cornerstone.

Chest X-ray gives an immediate first-hand look at the deformity and rib alignment.

CT scan (Computed Tomography) is a commonly used imaging method due to its ability to produce high-resolution cross-sectional images, allowing clinicians to assess severity using measures such as the Haller Index and Wenlin Index.

• Haller Index: One of the major measurements during the assessment process is the Haller Index, which is calculated with CT scans. This is a calculation of the chest's depth-to-width ratio. The average chest should have a Haller Index of around 2.5. A score of over 3.25 is generally considered serious and may qualify the patient for surgical correction. This numerical value provides an objective method for evaluating the severity of deformity between patients.

  
  

• Wenlin Index: However, due to the limitations of the Haller Index (extremely severe deformities may result in values approaching infinity or negative values), the ICWS developed and applied the Wenlin Index to assess the severity of pectus excavatum. This index is defined as the ratio of the depression depth to the distance from the anterior border of the spine to the plane of the depression's margin. A value <0.33 is considered mild, 0.33–0.67 is moderate, 0.68–1.0 is severe, and a value >1.0 is considered critical or very severe.

  
  

MRI (Magnetic Resonance Imaging) is usually chosen for children to avoid the radiation associated with CT scans, and can be used in certain cases to evaluate soft tissue anatomy and the sternum’s position relative to the heart.

These imaging modalities assist in defining the extent of chest wall depression, assessing potential compression of vital organs by the sternum, and generating three-dimensional reconstruction models to facilitate the planning of personalized surgical procedures.

3. Pulmonary Function Tests (PFTs)

Since pectus excavatum can reduce lung expansion, doctors often conduct PFTs. These tests measure the amount of air a person can inhale and exhale and how effectively the lungs transfer oxygen into the blood. Decreased lung capacity can indicate that the chest abnormality is constricting breathing function, especially during exercise.

4. Echocardiogram

Because the sternum could be compressing the heart, especially the right ventricle, an echocardiogram is usually performed. It is an ultrasound-based test that measures the heart’s size, shape, and pumping function. It can detect subtle defects, such as reduced cardiac output or valve insufficiency, which might be associated with severe pectus excavatum. Most importantly, it can reveal increased cardiac pumping pressures, such as pulmonary hypertension.

Can Conservative Treatments Correct Pectus Excavatum?

When patients and families are informed about what is pectus excavatum, one of the major concerns is whether it can be fixed without surgery. Not surprisingly, most would prefer to first attempt non-surgical fixes. While there are numerous pectus excavatum non-surgical treatments that can be attempted, their limitations must be realized. They may provide temporary cosmetic improvement or symptom relief, but cannot permanently correct the chest wall deformity.

1. Exercise and Posture Correction

Posture reeducation and physical therapy are typically recommended as adjunctive care. Deep breathing, flexibility exercises, and exercises to strengthen the chest and back muscles can result in better posture and slightly expand the lungs. These methods cannot, however, change the structure of the sternum or rib cartilage. They function optimally as adjunctive modalities that enhance global fitness and self-esteem, rather than as therapeutic treatments.

2. Vacuum Bell Therapy

The most controversial non-surgical treatment is the vacuum bell device.

It is a suction cup applied to the chest, which exerts negative pressure that gently pulls the sternum outward. In children and adolescents with minor deformities, long-term use can lead to considerable improvement. But it takes daily therapy lasting from 30 minutes to several hours, typically for years. Results are highly unpredictable, and relapse on cessation of treatment can occur. The method is rarely successful in adults or for patients with moderate to severe deformities.

3. Bracing

In cases of pectus carinatum, external bracing can be effective; however, for pectus excavatum, braces are not effective in correcting the defect. Since the deformity in pectus excavatum is a concave depression rather than a protrusion, external pressure cannot restore the chest to its normal shape.

While conservative therapy can help stabilize posture, boost confidence, or address minor cosmetic issues, it cannot correct the structural deformity itself. For moderate to serious cases of pectus excavatum, particularly when symptoms such as breathlessness or cardiac compression are present, surgery offers the most reliable and long-lasting solution.

Further reading: 3 Minimally Invasive Surgeries for Pectus Excavatum

Cure at ICWS

ICWS is a leading center and the world's largest specialized hospital for the treatment of chest wall deformities. Based on over 15 years of research into chest wall conditions, we have pioneered a number of innovative surgical procedures. Our team is capable of treating patients with even the most complex and rare chest wall deformities, having successfully performed over 10,000 surgeries for patients worldwide. At ICWS, patients benefit from access to the latest surgical techniques performed by chest wall deformity specialists.