Diagnosing Pectus Excavatum: Physical Exam, Haller Index, Imaging, and Additional Tests

Clinical Evaluation

1. Physical Examination

• Visual: sternal depression (central or asymmetric), costal flare.
• Palpation: depth, tenderness, respiratory excursion.
• Haller index (CT-based): transverse chest diameter / anterior-posterior depth at deepest point. >3.25 = severe; 2–3.25 = moderate; <2 = normal.
• Associated findings: scoliosis, Marfan habitus, pectus carinatum (mixed).

2. History

• Exercise intolerance, dyspnea on exertion, chest pain, palpitations.
• Psychosocial impact (body image).
• Family history (25% familial).

3. Imaging

• Chest X-ray (PA/lateral): Initial screening; calculates Haller index (less accurate than CT).
• Chest CT (inspiration/expiration): Gold standard for Haller index, cardiac compression, lung displacement, surgical planning.

4. Functional Assessment (If Symptomatic or Severe)

• Pulmonary function tests (restrictive pattern, reduced VC/FVC).
• Cardiopulmonary exercise testing (VO₂ max).
• Echocardiogram: cardiac compression, mitral valve prolapse, RV outflow obstruction.
• ECG: right axis deviation, RV hypertrophy.

Diagnostic Criteria

Haller index >3.25 on CT + symptoms or cardiopulmonary impairment → surgical candidate (Nuss or Ravitch procedure). Asymptomatic mild cases: observation.

Multidisciplinary Team

Pediatric/Thoracic surgeon, pulmonologist, cardiologist, physical therapist, psychologist.