What is pectus excavatum? The cause of a 'hole' in the chest
Pectus excavatum, derived from the Latin for 'hollowed chest,' is the most common congenital chest wall deformity. It is also known by other names, including funnel chest or sunken chest, and is characterized by an inward depression of the sternum (breastbone) and the surrounding ribs. This condition occurs due to an overgrowth of the cartilage that connects the ribs to the sternum, causing the bone to push inward.
While the exact cause remains unknown, it is thought to involve a genetic component, as it can run in families. It is also more prevalent in males than females, and in a minority of cases, it can be associated with connective tissue disorders like Marfan syndrome. The deformity can be present at birth but often becomes more noticeable and potentially more severe during adolescent growth spurts.
Symptoms associated with pectus excavatum
For many, especially those with a mild indentation, pectus excavatum is an aesthetic concern with no physical symptoms. However, moderate to severe cases can lead to a range of symptoms, particularly as the condition progresses. The severity of symptoms often correlates with the degree of sternal depression.
Key symptoms to watch for include:
- Shortness of breath: Particularly during physical activity or exercise, as the deformity can restrict lung expansion.
- Chest pain: Pain can occur due to the abnormal chest wall structure or muscle tension.
- Fatigue: Reduced exercise tolerance and stamina may be experienced because the heart and lungs cannot function efficiently, especially during strenuous activity.
- Heart palpitations: A fast-beating, fluttering, or pounding heart can occur in some individuals.
- Poor posture: Some patients may develop a curvature of the spine (scoliosis) or have rounded shoulders.
- Psychological distress: The visible indentation can cause self-consciousness, low self-esteem, and social anxiety, especially in teenagers.
When is a hole in the chest a medical concern?
While a mild pectus excavatum may be a benign cosmetic issue, any noticeable chest indentation warrants medical evaluation to rule out potential health complications and address psychological concerns. A doctor can assess the severity of the condition using a physical examination, imaging tests like a CT scan, and functional tests for the heart and lungs.
The Haller index, derived from a CT scan, is a key measurement used to determine severity. A higher index indicates a more severe deformity and a higher likelihood of it impacting the heart and lungs by compressing these organs. This compression is not life-threatening but can reduce lung capacity and impair the heart's pumping efficiency during exercise. The potential for reduced cardiovascular endurance and other symptoms justifies seeking professional medical advice, particularly during puberty when the deformity can worsen.
Other chest-related conditions to be aware of
While pectus excavatum is the most likely cause of a visible indentation, other conditions can affect the chest area. It is important to distinguish these, as they vary greatly in cause, symptoms, and urgency.
| Feature | Pectus Excavatum | Pectus Carinatum | Pneumothorax (Collapsed Lung) |
|---|---|---|---|
| Appearance | Sunken or caved-in chest | Protruding or 'pigeon' chest | Not a visible deformity; caused by air in the chest cavity |
| Cause | Congenital, unknown cause (possible genetics) | Congenital, unknown cause (possibly cartilage overgrowth) | Trauma to the chest, underlying lung disease, or spontaneous occurrence |
| Key Symptoms | Shortness of breath, chest pain, fatigue (in moderate/severe cases) | Often asymptomatic, but can cause chest pain and breathing difficulties during activity | Sudden, sharp chest pain and shortness of breath |
| Urgency | Non-urgent; typically addressed electively | Non-urgent; usually only a concern for appearance or severe symptoms | A medical emergency requiring immediate attention |
Diagnostic process for chest wall deformities
The diagnosis of pectus excavatum typically begins with a thorough physical examination and a review of the patient's medical history. Your doctor will assess the depth of the indentation and check for any associated conditions, such as scoliosis. To determine the severity of the deformity and its impact on internal organs, additional diagnostic tests may be ordered:
- CT scan: A computed tomography (CT) scan provides a detailed, cross-sectional view of the chest. It is used to calculate the Haller index, a ratio of the chest's width to its depth. An index over 3.2 is often considered severe and may indicate a need for surgical correction.
- Echocardiogram: An ultrasound of the heart to assess cardiac function and check for any compression or displacement caused by the sunken sternum.
- Pulmonary function tests (PFT): These tests measure how well the lungs work and can detect any restrictive lung patterns.
Treatment options for pectus excavatum
Treatment for pectus excavatum depends on the severity of the deformity, the presence of symptoms, and the patient's age and preferences. Options range from non-invasive therapies to surgical correction.
Non-surgical approaches
For mild to moderate cases, especially in younger patients with more flexible chest walls, non-surgical methods can be effective.
- Observation: In very mild cases, or in young children who are not yet experiencing rapid growth, a doctor may recommend simply monitoring the condition over time.
- Vacuum Bell Therapy: A non-invasive treatment that uses a suction cup-like device placed on the chest. The device creates a vacuum that lifts the breastbone, and consistent use over several years can permanently reshape the chest wall. This is often most effective for younger patients.
- Bracing: While more commonly used for pectus carinatum (pigeon chest), bracing can also be used in some cases of pectus excavatum. It applies external pressure to reshape the chest wall over time.
Surgical interventions
Surgery is typically reserved for severe cases where the deformity affects heart and lung function or causes significant psychological distress.
- Nuss Procedure (Minimally Invasive): A curved metal bar is inserted through small incisions on either side of the chest and positioned under the sternum. The bar is then flipped, which pushes the breastbone outward to a more normal position. The bar is left in place for two to four years before being removed in a second, minor procedure.
- Ravitch Procedure (Open Surgery): This more traditional and invasive procedure involves a larger incision to remove the abnormally growing cartilage. The breastbone is then moved into the correct position, sometimes with the use of a supportive strut.
Living with pectus excavatum
For most people with a mild form of pectus excavatum, the condition is not life-threatening, and they can lead full, normal lives without treatment. However, the psychological impact of the cosmetic deformity can be significant. Open and honest discussions between a parent, child, and healthcare provider are crucial for determining the best course of action. In many cases, successful treatment, whether surgical or non-surgical, significantly improves a patient's body image and self-esteem.
For severe cases, treatment can lead to improvements in heart and lung function, increased exercise tolerance, and reduced chest pain. The long-term prognosis for both surgical and non-surgical correction is generally very positive.
For more information on the condition, you can read more about pectus excavatum on the Mayo Clinic website.
Conclusion
So, is a hole in the chest normal? The answer is that while a mild chest indentation is common, it is a congenital deformity known as pectus excavatum and not a typical part of human anatomy. The vast majority of cases do not present an immediate danger, but proper medical evaluation is essential to understand the severity and address any physical or psychological symptoms. Treatment options are available for those who need or desire correction, with excellent results seen in many patients.
