Pectus Excavatum, also known as “sunken chest” or “funnel chest,” is the most common congenital chest wall deformity. It is caused by abnormal growth of the breastbone (sternum) and adjacent ribs, leading to a sunken appearance in the middle of the chest. The deformity may be mild and purely cosmetic, or severe enough to compress the lungs and heart, causing symptoms such as shortness of breath, fatigue, and chest pain. Beyond physical health, Pectus Excavatum often carries a significant emotional and psychological burden, particularly in adolescents and young adults who may struggle with self-esteem and body image.

This article provides a comprehensive overview of Pectus Excavatum, including its causes, pathophysiology, epidemiology, clinical features, diagnosis, differential diagnosis, treatment options, complications, prognosis, prevention strategies, and practical advice for living with this condition.

Pectus Excavatum is a structural deformity of the anterior thoracic wall where the sternum and surrounding costal cartilage grow inward, creating a concave appearance. The depth of the indentation varies, ranging from subtle to severe, and may become more pronounced during rapid growth phases, especially adolescence.

For many individuals, Pectus Excavatum is primarily a cosmetic issue. However, in moderate to severe cases, it can interfere with lung expansion and cardiac function. Pectus Excavatum is also associated with certain connective tissue disorders such as Marfan syndrome and Ehlers-Danlos syndrome, which affect the elasticity and structural integrity of connective tissues.

It is estimated to occur in approximately 1 in every 300–400 live births, with a higher prevalence in males than females. The condition is often noticed in early childhood but typically worsens during puberty as the chest wall grows rapidly.

The exact cause of Pectus Excavatum is not fully understood, but it is believed to arise from a combination of genetic, structural, and developmental factors.

Genetic factors

• Around one-third to one-half of individuals with Pectus Excavatum have a family history of chest wall deformities, suggesting a strong hereditary component.
• No single gene mutation has been identified, but familial clustering supports a genetic predisposition.

Connective tissue disorders

• More common in individuals with Marfan syndrome or Ehlers-Danlos syndrome, which weaken connective tissues and may predispose the chest wall to abnormal growth.

Abnormal costal cartilage growth

• Excessive or abnormal growth of the costal cartilage, which connects the ribs to the sternum, is the most widely accepted explanation. This abnormal growth displaces the sternum inward.

Intrauterine factors

• Some researchers suggest that conditions during pregnancy, such as uterine pressure or amniotic fluid imbalances, may influence chest wall development.

Neuromuscular disorders

• Children with neuromuscular conditions like spinal muscular atrophy (SMA) are at higher risk due to muscle weakness and poor chest wall support.

Other contributing factors

• Poor posture, weak pectoral muscles, or asymmetrical chest wall development may worsen the appearance but are not primary causes.

Pectus Excavatum occurs when abnormal growth of costal cartilage pulls the sternum inward. This results in a sunken chest wall and, in severe cases, compression of the heart and lungs. The deformity may become more prominent during puberty due to rapid skeletal growth. In children with flexible chest walls, progression is often noticeable during adolescence.

Cardiac compression can cause displacement of the heart to one side, reduced stroke volume, and arrhythmias. Lung compression may lead to reduced vital capacity, dyspnea, and decreased exercise tolerance. The severity of functional impairment varies widely between individuals.

• Prevalence: Occurs in approximately 1 in 300–400 live births.
• Gender: More common in boys than girls.
• Age: Often visible at birth or in early childhood but worsens during puberty.
• Association: Higher rates among individuals with connective tissue or neuromuscular disorders.

Physical appearance

• Visible indentation of the chest wall
• Asymmetry between the left and right sides
• Flared lower ribs
• Slouched posture

Respiratory symptoms

• Shortness of breath, especially during exertion
• Fatigue and reduced exercise tolerance
• Sensation of chest tightness
• Recurrent respiratory infections

Cardiovascular symptoms

• Palpitations or irregular heartbeat
• Dizziness or lightheadedness
• Fatigue even with mild exertion

Psychological and emotional effects

• Low self-esteem and poor body image
• Social withdrawal or avoidance of activities like swimming
• Anxiety or depression in adolescents and young adults

Diagnosis begins with a physical examination and may include imaging and functional studies to assess severity and impact on organ function.

Physical examination

• Visual inspection of chest wall deformity
• Assessment of depth and symmetry of indentation
• Evaluation for signs of respiratory or cardiac distress

Imaging studies

• Chest X-ray: Provides an overview of rib cage and sternum alignment.
• CT scan: Used to calculate the Haller index, the ratio of chest width to depth. A value greater than 3.25 typically indicates severe Pectus Excavatum.
• MRI: May be used to assess soft tissue involvement without radiation exposure.

Pulmonary function tests (PFTs)

• Measure lung capacity, airflow, and efficiency of breathing
• Useful in patients with dyspnea or reduced exercise tolerance

Cardiac evaluation

• Echocardiogram: Assesses heart displacement and function
• Electrocardiogram (ECG): Identifies arrhythmias or conduction abnormalities

Exercise testing

• Evaluates cardiopulmonary function during exertion
• Helps identify exercise-related symptoms

Differential diagnosis for Pectus Excavatum

Conditions that may mimic or be confused with Pectus Excavatum include:

• Pectus carinatum (pigeon chest)
• Poland syndrome (absence of chest wall muscles)
• Kyphoscoliosis (spinal deformities affecting chest shape)
• Other congenital chest wall anomalies

Accurate diagnosis and differentiation are essential for appropriate management.

Treatment is tailored to severity, functional impact, and patient concerns. Options include observation, non-surgical interventions, or surgical correction.

Observation (mild cases)

• For individuals with minimal symptoms, regular monitoring may be sufficient
• Recommendations include maintaining good posture, breathing exercises, and physical activity to strengthen chest and back muscles

Physical therapy and exercise

• Does not correct bone deformity but improves posture and muscle strength
• Focuses on core strengthening, breathing exercises, and flexibility training

Vacuum bell therapy

• Non-surgical option that uses negative pressure to gradually elevate the sternum
• Best for children and adolescents with flexible chest walls
• Requires consistent use over months to years

Surgical correction

Surgery is recommended for moderate to severe cases with functional impairment or significant psychological distress.

Nuss procedure

• Minimally invasive surgery using a curved metal bar placed behind the sternum
• Bar is flipped to push the sternum outward
• Bar remains in place for 2–4 years to allow remodeling
• Benefits include smaller incisions, shorter recovery time, and minimal scarring

Ravitch procedure

• More invasive, involves removal of abnormal cartilage and repositioning of sternum
• Sometimes uses support bars or struts
• Often reserved for adults, recurrent deformities, or cases unsuitable for the Nuss procedure

Psychological support

• Counseling and support groups can address body image concerns, social anxiety, and depression
• Emotional health support is especially important for adolescents

• Compression of heart and lungs leading to reduced function
• Arrhythmias or conduction abnormalities
• Recurrent respiratory infections
• Postural problems and musculoskeletal imbalance
• Psychological distress
• Risks associated with surgery, such as infection, bleeding, or recurrence of deformity

Prognosis depends on severity and treatment. Many individuals with mild cases live normal, healthy lives without intervention. For moderate to severe cases, surgical correction significantly improves cosmetic appearance, exercise capacity, and quality of life. Long-term outcomes are generally favorable with appropriate management.

There is no known way to prevent Pectus Excavatum, as it is primarily congenital. However, early detection, monitoring, and timely intervention can reduce complications. Maintaining good posture and chest wall strength may help minimize worsening of the deformity.

Living with Pectus Excavatum depends on severity. For many, it is primarily a cosmetic concern, while for others it impacts physical and emotional health. Strategies include:

• Regular medical monitoring
• Engaging in exercises that improve posture and breathing
• Seeking psychological support if body image or anxiety is an issue
• Discussing surgical or non-surgical treatment options with a healthcare provider

Pectus Excavatum is a common chest wall deformity that varies in severity and impact. While some individuals experience only cosmetic concerns, others face significant physical and emotional challenges. Advances in both surgical and non-surgical treatments have improved outcomes and quality of life for patients. With proper evaluation, monitoring, and individualized care, most people with Pectus Excavatum can achieve excellent long-term results.

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4. Haller, J. A., Kramer, S. S., & Lietman, S. A. (1987). Use of CT scans in selection of patients for pectus excavatum surgery: A preliminary report. Journal of Pediatric Surgery, 22(10), 904-906.
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