: Among patients suspected of pectus excavatum, visual examination is a key aspect of diagnosis and, moreover, guides work-up and treatment strategy. This study evaluated the inter-observer and intra-observer agreement of visual examination and diagnosis of pectus excavatum among experts.

: Three-dimensional surface images of consecutive patients suspected of pectus excavatum were reviewed in a multi-center setting. Interactive three-dimensional images were evaluated for the presence of pectus excavatum, asymmetry, flaring, depth of deformity, cranial onset, overall severity and morphological subtype through a questionnaire. Observers were blinded to all clinical patient information, completing the questionnaire twice per subject. Agreement was analyzed by kappa statistics.

: Fifty-eight subjects with a median age of 15.5years (interquartile range:14.1-18.2) were evaluated by 5 (cardio)thoracic surgeons. Pectus excavatum was visually diagnosed in 55-95% of cases by different surgeons, revealing considerable inter-observer differences (kappa:0.50; 95%-confidence interval [CI]:0.41-0.58). All other items demonstrated inter-observer kappa's of 0.25-0.37. Intra-observer analyses evaluating the presence of pectus excavatum demonstrated a kappa of 0.81 (95%-CI:0.72-0.91), while all other items showed intra-observer kappa's of 0.36-0.68.

: Visual examination and diagnosis of pectus excavatum yields considerable inter-observer and intra-observer disagreements. As this variation in judgement could impact work-up and treatment strategy, objective standardization is urged.