Continuing Education Activity

Pectus excavatum, commonly known as "funnel chest," is the most common congenital deformity of the chest wall characterized by posterior depression in the sternum and curvature of the associated costal cartilages. This activity reviews the epidemiology, proposed etiologies, clinical presentation, and cardiopulmonary and psychosocial consequences associated with sternal depression and thoracic asymmetry. This course also discusses the cardiopulmonary and psychosocial factors that impact functional outcomes. 

Participants will gain an understanding of the diagnostic evaluation and longitudinal assessment of pectus excavatum, including appropriate use of imaging, pulmonary function testing, electrocardiography, echocardiography, and severity indices such as the Haller index. The activity also outlines current consensus recommendations, indications for referral, the timing of intervention, and surgical and nonsurgical management strategies. This activity for healthcare professionals is designed to enhance the learner's competence in identifying pectus excavatum, performing the recommended evaluation, and implementing an appropriate interprofessional approach when managing this condition. 

Objectives:

• Identify key clinical features of pectus excavatum across patient populations.
• Apply evidence-based diagnostic approaches to evaluate disease severity in patients with pectus excavatum.
• Evaluate longitudinal monitoring strategies to detect progression of functional impairment in patients with pectus excavatum.
• Collaborate with interprofessional teams to coordinate patient-centered care to enhance outcomes for patients with pectus excavatum.

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Introduction

Pectus deformities account for approximately 95% of congenital chest wall anomalies, with the most common being pectus excavatum. Posterior depression of the middle to inferior sternum with curvature of the associated costal cartilages produces the characteristic "funnel chest" appearance (see Image. Pectus Excavatum). The manubrium and first and second ribs are usually not affected. Chest wall depression is commonly asymmetric and tends to deviate to the right. Usually diagnosed at birth, the severity of the depression may increase with growth.[1][2][3]

Etiology

The etiology of pectus deformity is unknown. Proposed mechanisms include weakness and abnormal flexibility of the sternum, excessive rib growth, and developmental failure of the bony thorax, intrauterine pressure, rickets, and diaphragm abnormalities.[4] Although identification of a specific genetic defect remains elusive, evidence supporting a genetic predisposition includes a positive family history, which is cited in 35% to 40% of cases.[5]

Epidemiology

Pectus excavatum occurs in 1 in 300 to 1 in 1000 live births and is the most common chest wall deformity. The defect is 5 times more common in males.[6] Most defects become apparent within the first year of life, with severe deformities appreciated at birth. The pubertal growth spurt is commonly associated with an increase in the prominence of the defect.[7] Pectus excavatum may present as an isolated anomaly, accompany other anomalies, or be a component of genetic syndromes, eg, Marfan's syndrome.[8] Musculoskeletal abnormalities (eg, scoliosis or kyphosis) are commonly associated with pectus deformities.

Pathophysiology

Decreased stroke volume detected on various cardiac studies in patients with pectus excavatum results in reduced exercise tolerance. Albeit normal at rest, the cardiac index decreases below predicted values with moderate exercise. Review of pulmonary function studies identifies mild to moderate decreases in forced expiratory volume in 1 second (FEV1) and vital capacity. Interestingly, subjective complaints by patients do not correlate with these objective results from cardiopulmonary testing.

History and Physical

Patients with pectus excavatum may be asymptomatic or experience chest pain, palpitations, or exertional dyspnea. Although asymptomatic, patients may suffer psychosocial distress as a result of the cosmetic defect or decreased exercise tolerance. Depression of the anterior chest wall at the level of the middle or inferior sternum is revealed by physical examination. Sidedness of the sternal deviation can be appreciated with more severe defects, and is more likely to be to the right. Additionally, in patients with pectus excavatum, the heart is often more displaced to the left. Ausculation of the thorax is necessary to assess for a cardiac murmur. 

Evaluation

Diagnostic evaluation of pectus excavatum includes a range of imaging and cardiopulmonary testing.

Diagnostic Studies

Although the posterior sternal depression can easily be detected on the lateral view of a chest radiograph, a chest computed tomography (CT) scan provides more detail. Various grading measures have been described. The pectus or Haller index is obtained from the chest CT scan, measured in the ratio of the transverse diameter at the widest point in the chest to the distance from the posterior sternal table and the anterior spine at the closest point. Normal Haller index values are 2.5 or less, while values above 3.2 indicate severe deformity.[6] Patients with a Haller index above 7 have a 4-fold increased risk of restrictive patterns on pulmonary function testing.[9] In cases of asymmetrical deformity, conventional Haller index measurement at the caudal sternum may be inaccurate; combining the asymmetry index measured at the sternomanubrial junction with the Haller index provides a more precise assessment.[10] 

Another grading method measures the anteroposterior distance between the sternum and spine and the distance between the spine and sternum at the angle of Louis. Magnetic resonance imaging (MRI), including breath-hold sequences, aids in preoperative evaluation of thoracic morphology. Advanced techniques, e.g., oculo-electronic plethysmography (OEP), reveal that the depressed sternum and adjacent chest wall exhibit reduced respiratory movement, resulting in decreased lung volume.[11] Without a consistent correlation with symptom severity, no method qualifies as an objective index.

Patients with mild pectus excavatum often experience minimal or no symptoms; however, cardiopulmonary evaluation to establish a baseline and monitor progression remains recommended every 1 to 2 years.[3][4][6][12][13] Axis deviation on the electrocardiogram (ECG) suggests leftward cardiac displacement. Arrhythmias, including first-degree heart block, right bundle branch block, and Wolff–Parkinson–White syndrome, occur in 16% of patients. Echocardiography evaluates cardiac compression, valvular defects, and myocardial function, as patients may exhibit leftward cardiac deviation and conduction abnormalities. 

Pulmonary function testing may reveal obstructive or restrictive lung disease in older patients, as well as air trapping with increased residual volume, often resulting from a mechanical disadvantage that impairs respiratory muscle function. Cardiopulmonary exercise testing can uncover limitations not evident at rest. Thoracic indices should be measured during end-expiration of quiet breathing.[14] Recent consensus recommendations include routine photography, spirometry for suspected pulmonary impairment, ECG and echocardiography for suspected cardiac involvement, along with a postoperative chest x-ray and follow-up photograph.[15]

Treatment / Management

Surgical Management

Corrective surgery for patients with pectus excavatum originated from the aggressive chest wall resection and reconstruction techniques employed in the management of asphyxiating thoracic dystrophy (Jeune syndrome). Current practice favors delaying surgical repair until after the pubertal growth spurt, using modified techniques that limit cartilage resection. Impaired cardiopulmonary function, rather than cosmetic concerns, serves as the primary indication for surgery.[16][17][18]

Chest wall resection

Ravitch documented the first pectus excavatum repair, citing subperichondrial resection of all deformed costal cartilages and the xiphoid.[19] Rehbein and Wernicke modified this procedure by adding longitudinal or transverse metallic bars to stabilize the sternum and reoperating 1 year later to remove the bar.[20] Modern adaptations of the Ravitch procedure use orthopedic plates and screws, which can be custom-modeled to the patient’s anatomy and do not require subsequent hardware removal.

The chest wall is approached via a longitudinal sternotomy or transverse submammary incision, which female patients often prefer. Skin flaps are elevated from the angle of Louis to the xiphoid process, and the pectoralis and serratus anterior muscles are elevated off the sternum. The anterior aspect of the perichondrium is incised to dissect and excise the costal cartilages. The level of the last deformed cartilage is the site of the sternal osteotomy, commonly just above the third cartilage.

Minimally invasive techniques

The minimally invasive technique described by Nuss and Kelly involves inserting a metal bar beneath the posterior sternum at the most depressed zone and the most everted costal lines on both sides of the chest.[21] The retrosternal bar is positioned thoracoscopically through 2 to 3 cm mid-axillary incisions. Skin flaps are raised and tunneled to the identified intercostal spaces. A metal introducer creates a retrosternal plane between the anterior pericardium and posterior sternal table, which is exteriorized through the left incision, attached to a titanium rod, and withdrawn. Rotating the bar so the concave side faces posteriorly pushes the sternum anteriorly. Metallic stabilizers, surgical steel wires, and heavy suture are used to prevent bar migration. Although the initial stabilization period was 2 years, current practice often leaves the bar in situ for 3 years.

Additional modifications have been proposed to both surgical approaches, some resulting in improved outcomes. Recent use of intercostal nerve blocks for postoperative analgesia has significantly reduced hospital length of stay.[22] Leonard's modification excises the lower costal cartilages while preserving the perichondrium after mobilizing the pectoralis muscles.[23] Robicsek attached Marlex mesh to residual costal cartilage to stabilize the posterior sternum at the level of the osteotomy.[24] Erlangen’s adaptation of the Nuss procedure implants a transternal elastic metal bar through stitch incisions, using intraoperative tensiometry to minimize cartilage resection.[25] Lacquet’s magnetic miniprocedure uses magnetic forces between a sternal magnet and a patient-worn brace to pull the sternum anteriorly, avoiding prosthetic materials and achieving superior results for asymmetric defects compared with the traditional Nuss technique.[26]

Nonsurgical management using negative thoracic pressure provides an alternative for select patients.[27] A vacuum bell applied to the chest wall defect creates negative pressure via a hand pump. While long-term outcomes remain under investigation, this approach offers a potential option for managing less severe deformities and may benefit younger symptomatic patients in whom prepubertal surgical correction is not indicated.

Differential Diagnosis

Differential diagnoses that should also be considered when evaluating patients for pectus excavatum include:

• Ehlers-Danlos syndrome

• Marfan syndrome

• Noonan syndrome

• Scoliosis

Prognosis

Surgical correction of pectus excavatum produces a noticeable cosmetic improvement. Optoelectronic plethysmography has demonstrated improvement in regional chest wall movement dysfunction following repair.[28] Despite these functional improvements, clinical outcomes, eg, cardiorespiratory fitness, remain controversial. Improvements in pulmonary function testing appreciated in the early postoperative period dissipate with time, presumably due to decreased chest wall compliance. A recent meta-analysis of 15 studies, selected from 1,598 screened, found no significant change in maximum oxygen uptake before and after surgical correction of pectus excavatum.[29] Patients undergoing revision surgery after a failed initial repair face higher risks and a greater likelihood of complications.[30]

Complications

Complications that can occur with surgical resection include: 

• Bar migration
• Infection
• Pneumothorax
• Bleeding
• Cardiac laceration
• Chronic pain
• Recurrence

Overall morbidity and length of stay are comparable for Ravitch and Nuss procedures, according to a recent meta-analysis.[31] However, the incidence of postoperative hemothorax and pneumothorax, as well as the rate of return to the operating room, is higher with the Nuss procedure. The comparison done by Antonoff et al included the Ravitch, Nuss, and Leonard procedures. The analysis clearly demonstrated longer length of stay, higher costs, more narcotic use, and higher morbidity in the Nuss cohort.[32] Subjectively, the Nuss and Ravitch procedures appear to be comparable, based on similar health-related quality-of-life (HRQL) outcomes.[33]

Deterrence and Patient Education

Deterrence of complications associated with pectus excavatum relies on early recognition, appropriate monitoring, and timely intervention. Clinicians should focus on identifying patients at risk for cardiopulmonary impairment, arrhythmias, or progressive thoracic deformity, particularly during growth spurts. Regular follow-up, including chest radiographs, pulmonary function testing, electrocardiography, and echocardiography, helps detect functional decline before it becomes severe. Measuring thoracic indices, eg, the Haller index and asymmetry index, guides clinical decision-making and surgical planning. Selecting the optimal timing and technique for surgical correction—whether minimally invasive or open procedures—reduces postoperative complications and enhances long-term outcomes. Nonsurgical alternatives, eg, vacuum bell therapy, may also prevent progression in younger or less severely affected patients, while limiting the need for prepubertal surgery.

Patient education plays a critical role in managing pectus excavatum. Although patients and parents are more likely to search the internet for health information regarding pectus excavatum, the overall quality of such websites was reported to be low to moderate.[34] Therefore, the onus for patient education lies with the health care team. Healthcare professionals should explain the condition, potential cardiopulmonary effects, and psychosocial implications, particularly for adolescents concerned about appearance. Patients and families must understand the rationale for ongoing monitoring, the benefits and risks of surgical and nonsurgical options, and expected postoperative recovery, including pain management and activity restrictions.

Additionally, patient education is an essential component of the recovery protocol. A recent study showed a reduced length of hospital stay and decreased use of opioids in patients on a postoperative protocol consisting of patient education, bowel management, and pain management.[35] Nutritional education was beneficial for patients with moderate pectus excavatum.[36] Clear communication regarding the possibility of arrhythmias, exercise intolerance, and long-term functional outcomes empowers patients to participate in shared decision-making. Reinforcing adherence to follow-up schedules, imaging, and pulmonary assessments helps optimize safety, functional outcomes, and quality of life while fostering confidence and engagement throughout the treatment process.

Enhancing Healthcare Team Outcomes

Pectus excavatum is the most common congenital chest wall deformity, characterized by posterior depression of the sternum and adjacent costal cartilages. Although often identified in childhood, severity and clinical impact may progress during adolescence. While some patients remain asymptomatic, moderate to severe deformities can impair cardiopulmonary function, contribute to exercise intolerance, and cause arrhythmias or valvular abnormalities. Psychological distress, particularly during adolescence, is also common. Evaluation includes imaging, pulmonary function testing, electrocardiography, and echocardiography, with severity quantified using indices such as the Haller index to guide monitoring and management decisions.[4][7][37]

Optimal management of pectus excavatum relies on coordinated interprofessional care. Physicians, general practitioners, and advanced practitioners are responsible for early recognition, longitudinal assessment, and appropriate referral based on functional impairment rather than cosmetic appearance alone. Nurses play a key role in patient education, symptom monitoring, and postoperative care. Pharmacists contribute to safe analgesic management and medication reconciliation, particularly in the perioperative period. Effective interprofessional communication ensures accurate interpretation of diagnostic findings, timely intervention, and shared decision-making. Coordinated care enhances patient safety, improves functional outcomes, supports psychosocial well-being, and strengthens overall team performance.

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Disclosure: Girish Sharma declares no relevant financial relationships with ineligible companies.

Disclosure: Yvonne Carter declares no relevant financial relationships with ineligible companies.