haller index

Haller Index for Pectus Excavatum

The Haller Index is an easy mathematical calculation to measure the severity of the pectus excavatum deformity. 

It is also known as pectus index.

Throughout the years, the Haller Index has been helpful for surgeons to rate the severity of the pectus excavatum deformity.

In this article I'll discuss about how this mathematical calculation was invented, whether it gives the accurate information and much more.

Beginnings

haller index history

Over the years, pectus excavatum awareness has increased.

People who suffer from it are conscious of the negative health effects caused by the deformity.

Because of that, they are asking for medical treatment.

Surgeons needed some directions to determine whether the patient's health is severely affected by the deformity and demands immediate surgery.

The Haller Index proved to be effective in what the surgeons were looking for.

It was created in 1987 by Jacob Alexander Haller Jr., who was an American pediatric surgeon, together with Sandra S. Kramer and Steven A. Lietman.

They developed this calculation in Baltimore, Maryland.

Generally, patients with a higher Haller Index would benefit more from surgical correction. 

Oppositely, patients with a lower HI don't require surgery because the deformity is probably just cosmetic and doesn't affect the internal organs.

KEY POINT:

Surgeons were seeking for a simple way to measure the severity of the pectus excavatum deformity. The Haller Index proved to be effective in doing that.

​3 Measurement Methods

how is haller index measured

The Haller Index can be measured in three different ways.

  • CT Scan
  • MRI (Magnetic Resonance Imaging)
  • Chest Radiography

Up until recently, doctors thought the most accurate way to measure the severity of pectus excavatum was a computed tomography (CT) scan.

A 2010 study proved there were statistically similar connections between the radiographic Haller Index and CT Haller Index.

They concluded the CT Scan wasn't required for calculating the severity of the pectus excavatum deformity.

A simple two-way chest radiograph was safer and just as effective.

Now it is a common practice for surgeons to use chest X-rays, and not CT scans, mostly because of decreased radiation exposure on the patients.

KEY POINT:

All three techniques for Haller Index measurement are used. However, a chest radiography is proven to be just as effective as a CT Scan.

Mathematical Calculation

mathematical calculation severity of concave chest

In simple terms, the Haller Index measures how wide (transverse diameter) the chest is, compared to its depth (anterior-posterior diameter).

After a CT scan, surgeons divide the distance between the left and right rib (A), with the distance between the spinal cord and the sternum (B).

If distance A is 90 mm, and distance B is 20 mm, then the Haller Index will be 4.5, which is considered severe.

That's how you calculate the Haller Index, which can reach as high as 5.5.

What is a Normal Score

As stated by this research, a typical, flat-chested person has a HI of about 2.5 to 2.7.  

Ranges from 2.5 to 3.0 are considered a slight case of pectus excavatum.  

HI ranging from 3.0 to 3.25 is moderate

All ranges higher than 3.25 are very serious and require treatment immediately.

How a Person with High HI Feels

The heart of a person with a Haller Index > 3.25, is probably displaced to the side. 

Also, the right lobe of the liver can be squeezed by the malformed ribcage. 

The indented breastbone is pushing the internal organs inward. 

These patients also have everyday pain in the chest and back. Sometimes the pain is very bad, and sometimes it is tolerable.  

The pain is usually concentrated around the protruding ribs, the deepest part of the chest. 

Lots of pectus excavatum sufferers with a Haller Index higher than 3.25. said the pain feels like you're about to have a heart attack.  

The back pain makes it hard for you to bend over, twist side-to-side.

If you have a job that demands lots of physical activity and lifting stuff, the pain is aggravated. 

It goes to the point that it becomes hard to swallow.

Surgeons believe the severe indentation of the chest can press against the esophagus, which makes swallowing harder.

KEY POINT:

If a person has a high Haller Index, let's say in the range above 4.0, then he is probably having sharp chest and back aches.

​Biggest Problems

The biggest disadvantage of the Haller Index as a regular severity measurement of pectus excavatum is that it isn't determined consistently.

Surgeons always face significant variations in the Haller Index estimation methods.

A change in any of these three details can yield a different Haller Index score.

  • The transverse plane used to estimate the anterior-posterior depth of the dent in the chest (deepest point of the dent in opposition to a standardized point).
  • Whether the patient is inhaling or exhaling when the calculation is performed.
  • Which medical imaging modality is being used (MRI, CT Scan or Chest Radiography).

Small changes in the measurement technique can be the difference between undergoing surgery or following a non-surgical approach to repair the deformity.

In some cases, a patient who has a severely inverted chest that affects the lungs and heart can have a lower HI than a patient who used a different measurement technique.

The second patient with a higher HI score can only have a cosmetic deformity that doesn't affect his organ functioning. 

The first patient won't undergo a surgery because the Haller Index isn't high enough.

Then, he will try to rely on physical therapy and other non-surgical treatments to fix the condition.

However, this will be a slow and tough process that may take a few years until he sees a full correction.

The second patient with a higher HI score will undergo a surgery that will probably require two titanium bars to be inserted below his sunken breastbone.

He will need to live with the bars for about three painful years. This will stop him from playing contact sports and living life to the fullest.

The problem is that the second patient could fix the deformity much faster, cheaper and painlessly, using the vacuum bell device treatment and performing pectus excavatum physical exercises.

In this case, a surgery wouldn't be the best option.

The first patient requires quick surgery because the condition is causing him severe health problems.

Insurance Companies Don't Cover Surgery Costs

Additionally, most insurance companies don't cover the costs of a pectus surgery if the Haller Index is lower than 3.25.

This is the biggest problem with the Haller Index measurement. 

For example, an 18-year-old with congenital pectus excavatum sufferer that has exercise intolerance and shortness of breath will be denied from taking financial coverage for surgery, if the Haller index is let's say 3.10.  

The shortness of breath and physical weakness will become more intense when he becomes 30 years old.

That will require surgery to repair the deformity because it will probably lower the patient's lifespan.

However, the Haller Index will remain at 3.10. The patient's surgical coverage will get denied again.

Surprisingly, this is quite an often situation.

KEY POINT:

The Haller Index mesurement can be inconsistent. Also, the insurance companies aren't willing to cover the costs for surgey for patients with a HI lower than 3.25.

Cut Off Value

In a book about chest wall deformities published in December 2015, 334 pectus deformities specialists were surveyed.

More than 50% of them stated the threshold of 3.25. to be inaccurate.  

Plenty of surgeons agree that the pectus excavatum severity shouldn't be divided into groups below, or above 3.25.

Relying on the Haller Index alone, surgeons can't predict how negatively the patient is affected by the deformity, both psychologically or physically. 

In this study, surgeons Robert Eisinger and Hans Pilegaard agree with the beliefs of more than half of the chest wall deformity specialists and don't measure the Haller Index at all. 

They also ask health coverage companies to examine other factors, and not just the Haller Index, when it comes to covering the surgery costs.

KEY POINT:

Plenty of surgeons agree the requirement to have a Haller Index score above 3.25 as a threshold for a surgery to be innacurate.

My Problem With HI

From a medicinal point of view, it is completely incorrect the pectus excavatum surgical procedures like the Nuss or Ravitch, to be planned just for people with a Haller Index greater than 3.25. 

Lots of patients and surgeons want the cut-off point to be set as low as possible.

That way, patients that feel negative physical and mental effects caused by the deformity, can be reasonably operated.

Take the example of the BMI (body mass index) calculation.

A lot of informational websites on the internet determine obesity only based on BMI calculations.

For example, take Robert Harting, who is a German Olympic discus thrower. During his career, he has won 7 Gold Medals.

When he won his last gold medal in Zurich, in 2014, he was 30 years old, standing at 2.01m (6 ft 7 in), weighing 126 kg (278 lbs).

If you use NIH's certified BMI Index, his Body Mass Index is 31.3. 

According to the World Health Organisation BMI categories, a person is obese if he has a BMI of 30 or greater.

How can an Olympic athlete who is at the prime of his career, winning Gold medals, year by year, be categorized as obese?

Certainly, about 90% of all people find the BMI to be accurate. But what about the remaining 10%?

It is not different from the Haller Index calculation. 

PE Severity Can't Be "Mathematically" Calculated

The severity of pectus excavatum and how critically it is affecting the vital internal organs cannot be calculated so easily.

In some cases, the HI doesn't provide any value.

It's just a calculated result based on width and depth. With it, you can't look at the organs inside your body.

You need to check the internal structure of the malformed chest.

Check the positioning of the heart and lungs.

See whether your lungs are squeezed or whether your heart is displaced to the side. 

That's how you see if the pectus excavatum deformity is causing you health troubles.

The surgeon giving you a Haller Index score is the same as if Robert Harting went to the doctor to check his BMI score.

KEY POINT:

The HI can't tell everything about the pectus excavatum severity. You have to check the internal organ structure to see whether the deformity is harmful. It is similar with BMI in telling a patient whether he or she is in the healthy weight range.

3D Optical Imaging - Alternative Technique

In October 2018, a couple of medical doctors and Ph.D.'s at Stanford University, California, published a study that proves three-dimensional scanning to estimate the severity of chest wall indentation, without any radiation exposure.

In the study, the patient's chests were scanned with a 3D structured light camera.

3D Optical Imaging Technique seems promising as a great alternative to the Haller Index measurement of pectus excavatum severity.

It would be beneficial to have a few extra studies on this subject to further establish this technique.

KEY POINT:

It is scientifically proven the 3D Optical Imaging to be a great alternative to the Haller Index.

Conclusion

Nowadays a simple chest radiograph or a CT scan are the two most commonly used ways to measure the Haller Index. 

Even though most surgeons agree on its usefulness, they also agree it can give the wrong picture about the seriousness of the deformity. 

To know whether the deformity affects your internal organs, you must see their internal structure. 

You can't conclude that just by knowing your Haller Index.

For example, take two people who have a HI of 3.8.

The internal organs in one patient may not be affected at all, and in the other they can be pushed to the side, causing cardiac and respiratory system problems.

At the end of the day, you won't lose anything if you know your chest Haller Index. However, make sure you also inspect the positioning of your internal organs.

That's the best way to know whether you need surgery or not.

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