Overview

Pectus Excavatum (PE) is a condition that some people are born with, where the breastbone (the long flat bone in the middle of the chest) and nearby ribs grow inward instead of outward.¹ This causes a dent or hollow in the chest, which is why it's sometimes called "funnel chest" or "sunken chest. PE affects approximately 1 to 8 individuals per 1,000 in the general population.¹ While PE is often associated with childhood, this condition persists into adulthood and can have significant physical and psychological impacts on sufferers. This article aims to provide a thorough examination of PE in adults, focusing on its causes, and symptoms as well as the treatment options and outcomes for dealing with this condition.

Causes 

The exact cause of PE remains unknown for the majority of cases. However, research has identified several potential contributing factors:²

1. Genetic predisposition: While no specific genetic link has been identified, approximately 40-50% of individuals with the condition have a family history of the condition or related disorders
2. Connective tissue disorders: PE is frequently associated with connective tissue diseases such as Marfan syndrome and Ehlers-Danlos syndrome
3. Disproportionate growth: A leading theory suggests that PE may result from uncoordinated growth between the ribs and the chest. If rib growth outpaces the expansion of the heart and lungs, which normally push the sternum outward, the sternum may be forced inward

Symptoms

In adults, PE can cause both physical and psychological symptoms. 

Physical symptoms:

Cardiopulmonary effects³

PE can restrict heart and lung function, leading to:

• Shortness of breath and fatigue (especially during exercise)
• Chest pain
• Cardiac compression, potentially causing:
  • Irregular heartbeat
  • Heart palpitations

Musculoskeletal issues¹

PE can lead to compensatory changes in posture, potentially causing:

• Back pain
• Shoulder discomfort

Psychological symptoms

1. Body image issues: People with PE can suffer from feelings of embarrassment or self-consciousness about their appearance with the altered chest shape negatively impacting their self-esteem and/or body confidence
2. Clinical depression: In severe cases, the psychological burden of PE can contribute to the development of clinical depression

Diagnosis

PE in adults can be diagnosed using various methods.³ Physical examinations are most commonly used to assess the severity of the chest deformity. Imaging techniques such as computer tomography (CT) and magnetic resonance imaging (MRI) scans on the other hand are used to evaluate the extent of the deformity and its impact on a person's internal organs. The Haller index, calculated from CT scans, is a widely used measure of PE severity, with an index greater than 3.25 generally considered severe.⁴ In addition to physical examinations of the chest and imaging pulmonary function tests can be used to assess lung capacity and function, while cardiovascular evaluations, including echocardiograms (ECGs), can be used to examine heart performance.

Treatment options

Most adults with PE don't require surgical intervention.¹ However, treatment may be considered for those experiencing significant physical symptoms or psychological distress from the condition. Whether or not someone receives or chooses to have treatment is usually based on the severity of their symptoms and the impact the condition is having on their overall quality of life.

Surgical options for treating PE include:

1. Nuss Procedure: A minimally invasive surgery that involves the insertion of a curved metal bar behind the sternum to push it outwards⁵
2. Ravitch Procedure: An open surgery where the surgeon repositions the sternum directly⁵

Both procedures aim to reposition the sternum, reducing pressure on the heart and lungs while improving chest appearance. While surgical correction can be successful at any age, studies suggest that earlier intervention often leads to better outcomes. In particular, the Nuss procedure can be more challenging in adults due to their reduced chest wall flexibility. The degree of chest wall deformity also influences outcomes with more severe deformities experiencing more significant improvements post-surgery.⁶ Studies show mixed results regarding the cardiopulmonary improvements after surgical correction although generally those who have undergone surgery report improved exercise capacity and cardiopulmonary function.⁷ An additional consideration to the success of the procedure is that, like all other surgeries, it comes with potential side effects and complications. Reported complications of these procedures include pneumothorax, bleeding, infection, chronic pain, and injury to surrounding structures in the chest.⁵ For adults with milder cases of PE or for those who prefer non-surgical options, alternative treatments are also available:

1. Physical Therapy: Exercises can help improve posture and chest muscle strength, potentially alleviating some symptoms⁸
2. Cosmetic Solutions: For those primarily concerned with appearance, custom-made implants can be considered to improve chest contour without addressing functional issues⁹

Living with Pectus Excavatum

Living with pectus excavatum often requires ongoing medical management. Regular check-ups with healthcare providers are important to monitor any changes in heart and lung function. Many individuals also find support groups or counselling helpful in dealing with the psychological aspects of the condition. Despite the challenges, many adults with pectus excavatum lead full, active lives.¹⁰ With proper management and support, individuals can mitigate the physical limitations and psychological impacts of the condition, allowing them to pursue their personal and professional goals without significant hindrance.

FAQ’s

Can Pectus Excavatum worsen in adulthood?

Yes, pectus excavatum can worsen in adulthood, especially during growth spurts or with age-related changes in chest wall flexibility. Regular monitoring is recommended to track any progression.

Will Pectus Excavatum affect my ability to have children?

Pectus excavatum generally doesn't directly affect fertility or the ability to have children. However, severe cases might impact pregnancy comfort or complicate delivery. Consult with your doctor for personalised advice.

Can I exercise with Pectus Excavatum?

Most adults with pectus excavatum can exercise, but some may experience reduced exercise tolerance or shortness of breath. Start with low-impact activities and gradually increase intensity, always listening to your body and consulting with a healthcare provider.

Is surgery the only treatment option for adults?

No, surgery isn't the only option. Depending on severity, treatments can include physical therapy, vacuum bell therapy, or cosmetic solutions. Surgery is typically considered for severe cases or when symptoms significantly impact quality of life.

Can Pectus Excavatum cause heart problems later in life?

Severe pectus excavatum can potentially lead to heart issues due to compression of the heart. Regular cardiac evaluations are important to monitor for any developing problems. Many adults with the condition, however, don't experience significant cardiac complications.

Summary

Pectus Excavatum is a complex condition with significant physical and psychological implications. While the exact causes of the condition remain unclear, genetic factors and growth abnormalities likely play key roles. The condition can lead to cardiopulmonary complications and psychological distress both of which impact people with PE overall quality of life. Diagnosis involves comprehensive physical examinations and imaging studies, with the Haller index serving as a measure of severity for the disorder. Treatment options range from conservative approaches like physical therapy to surgical interventions. While surgery can improve both physical function and the psychological well-being of people with PE, outcomes vary based on the age and the original severity of the deformity pre-surgery.