The Diagonal Ear Lobe Crease Or Franks Sign

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One of the most investigated auricular signs in the literature is undoubtedly the diagonal ear lobe crease (ELC). When Frank10 in 1973, in a letter to the New England Journal of Medicine, described his 'aural sign of coronary artery disease' he cannot have imagined that he would trigger a long and unbroken series of researches all over the world. There are probably 40 or more reports and articles in the literature, written mainly by cardiologists, dealing with the following aspects of the question:

• Is ELC a reliable diagnostic sign of coronary heart disease (CHD)?

• Does it have a predictive value for cardiac events such as cardiac death, acute myocardial infarction or coronary bypass operation in high risk patients?

• Can ELC be associated with conventional risk factors such as hypertension, smoking, diabetes, cholesterol, triglycerides, obesity, etc.?

• Should ELC be considered a sign of aging of the cardiovascular system?

• Should ELC be considered an androgen-sensitive trait like baldness and ear-canal hair?

Several authors tried to answer these questions but none of them was curious enough to seek a correlation with the representation of the homunculus on the pinna. On the other hand only a few acupuncturists were making an effort to understand the strange topography of a sign which apparently seems totally unrelated to the representation of the cardiovascular system.

As regards the investigations carried out by cardiologists, Tables 4.6 and 4.7 report a (probably incomplete) list of articles published in the period between 1974 and 2007.11-49 While waiting for a complete systematic review on this topic the following information can be summarized from the tables:

1. ELC manifests itself after the age of 40 but becomes more evident and frequent around the sixth and seventh decades of life, especially in males. There is a general consensus that those patients showing an ELC before 40 have a higher risk of cardiovascular disease. Also performing an age- and sex-matched comparison with non-ELC subjects, the crease seems to be significantly correlated with a higher prevalence of CHD and a higher score of coronary stenosis in patients undergoing angiography (Table 4.6). Even in post-mortem studies there is a strong correlation between ELC with both the cardiovascular cause of death and the degree of atherosclerosis in the coronary and cerebral arteries and in the aorta (Table 4.7).

2. ELC may manifest unilaterally or bilaterally. Bilateral ELC, especially deep and clear-cut creases, seem prospectively to be associated with a lower cardiac event-free survival.36

3. There is often a lack of association between ELC and the conventionally accepted risk factors. This inconsistency, whenever confirmed by a systematic review, closely recalls the controversy in the literature about the real importance of these factors. Indeed, it is still suggested by different authors that 50% of patients with CHD lack any of the conventional risk factors.

This implies that other non-traditional factors could play a significant role in the development of this disease. However, the factors which seemingly show a higher association with ELC are hypertension and obesity.

4. ELC can be considered an indicator of biological age as opposed to chronological age and could be used to identify subjects who are aging more quickly than the general population. Biopsy sections from ear lobes at the site of the crease19 report a premature destruction of elastic fibers in the skin which is similarly correlated with coronary artery disease (Fig. 4.9A, B).

5. Some articles report a possible association between CHD, ELC, ear-canal hair and male-pattern baldness. This association is supposed to be due to the long-term exposure to andro-gens which may facilitate the development of atherosclerosis and CHD.

Table 4.6 Study groups: association of ear lobe crease (ELC) with acute myocardial infarction (AMI) and coronary heart disease (CHD); association of ELC with the conventional risk factors. A review of the literature 1974-2007


Study groups

Association of ELC with AMI/CHD

Association of ELC with conventional risk factors

Lichstein (1974)

531 patients with AMI vs. 305 patients in a control group with no clinical evidence of CHD

ELC in 47% in the first group vs. 30% in the control group (P<0.001)

Negative association with diabetes mellitus and hypertension

Smoking prevalent in the AMI group with ELC vs. no ELC (P<0.005)

Mehta (1974)

211 patients undergoing coronary angiography: 159 with CHD; 52 with normal coronary arteries

No different frequency of ELC in the two groups

The prevalence of ELC increases with age

Christiansen (1975)

503 unselected patients admitted to a medical and a surgical department

The prevalence of ELC increases with age, but is significantly higher (46%) in patients over 50 with AMI/CHD vs. control group (31%) (P<0.02)

Not clearly reported prevalence ratios about hypertension, smoking and diabetes mellitus

Andresen (1976)

101 diabetic patients

ELC observed in 51.4% of patients with retinopathy compared to 7.6% with normal retinal vessels


Table 4.6 Study groups: association of ear lobe crease (ELC) with acute myocardial infarction (AMI) and coronary heart disease (CHD); association of ELC with the conventional risk factors. A review of the literature 1974-2007—cont'd


Study groups

Association of ELC with AMI/CHD

Association of ELC with conventional risk factors


1237 men aged 50-74 from a

No different frequency of ELC in

Weak association of ELC with


cross-section of the population of

CHD of any type vs.

hypertension. Strong association


asymptomatic people

with obesity

Kaukola (1978)

Study group A: 288 patients <65 with AMI vs. 290 normal subjects

ELC observed in 69% vs. 24% (P<0.01 for patients aged 30-39, P<0.001 for the other age groups)

Kaukola (1978)

Study group A: 288 patients <65 with AMI vs. 290 normal subjects

ELC observed in 69% vs. 24% (P<0.01 for patients aged 30-39, P<0.001 for the other age groups)

Study group B:

286 randomly selected patients undergoing coronary angiography:

200 with at least 50% stenosis in one of the main coronary arteries (CHD patients) vs. 86 without significant stenosis (<50%; non-CHD patients). Groups comparable in age

ELC observed in 72% of patients with single, double and triple vessel disease vs. 21% of patients with no significant atherosclerotic changes in coronary arteries (P<0.001). The prevalence of ELC increases with age and severity of the heart disease, being positive in nearly 90% of CHD patients with triple vessel disease aged 50-59 years

Negative association between ELC and smoking, hypertension, cholesterol, triglycerides, diabetes mellitus, family history of diabetes, obesity, level of physical activity, blood group, birth place The only significant difference was for patients with ELC of study group A having a family history of premature cardiovascular disease (P<0.01)

Moncada 300 healthy subjects: 150 with (1979) ELC, 150 age-matched controls

Positive association of ELC with hypertension, eye ground changes and ECG ischemic findings

Kristensen 125 hypertensive patients (74 (1980) male, 51 female);

55 normotensive subjects (29 male, 26 female)

Positive association in males between ELC and hypertension (P<0.005)

Shoenfeld 421 consecutive patients with (1980) AMI vs. 421 controls

ELC as a deep wrinkle extending for a distance greater than or equal to one-third of the ear lobe length, evaluated by an independent assessor on one or both auricles, while the subject was supine and seated ELC biopsies performed in 12 subjects

ELC observed in 77% of the AMI group vs. 40% of the control group (P<0.05)

Positive association between ELC and hypertension (P<0.001), and diabetic retinopathy (P<0.05) No significant association with diabetes, hypertensive retinopathy, hyperuricemia, hyperlipidemia, smoking

Chen 729 hospital staff members with

(1982) bilateral ELC during a lipid profile examination

Negative correlation between abnormal serum cholesterol and ELC


340 selected patients undergoing

Sensitivity of ELC rated 59.5%,

Negative association between


coronary angiography

specificity 81.9%, positive

ELC and family history of AMI or

Degree of occlusion graded from

predictive value 91.1%

sudden death before the age of

0 to 3 (grade 1 = 30-50%

79 patients with ELC vs. 35

55, smoking, systolic and diastolic

reduction in the diameter of one

without ELC both having grade 3

pressure, cholesterol,

or more of the main vessels;

of coronary occlusion (P<0.001)

triglycerides, blood glucose

grade 2 = >50% reduction in

one or two main vessels; grade

3 = >50% reduction in three

main vessels)


234 veterans (average 66 years

No different frequency of CHD in

No prevalence as regards body


old): 119 with ELC; 115 without

the two groups

weight, diabetes, blood pressure,

cholesterol, urea, creatinine, uric



1000 unselected patients

ELC observed in 73.1% of CHD

No prevalence as regards family


admitted to various hospitals:

patients vs. 19.2% of non-CHD

history, smoking, hypertension,

376 with CHD vs. 624 non-CHD

patients (P<0.00001)

diabetes mellitus, cholesterol



63 unselected patients

ELC associated with CHD


undergoing coronary angiography


Association between ELC and

ELC + ear-canal hair associated

ear-canal hair in stenosis >50%

with CHD (P<0.05)

of one or more coronary arteries


100 patients with aortic valve

No correlation between ELC


stenosis undergoing coronary

scoring and degree of coronary



Degree of occlusion graded from

0 to 5

ELC scored for each side from 1

to 3 (total scoring from 0 to 6)


Study group A:

ELC observed in 24.5% of CHD

No prevalence of obesity,


1000 unselected patients

patients vs. 4.8% of non-CHD

hypertension, diabetes mellitus,

237 patients with angina pectoris

patients (P<0.001)

smoking and hyperlipidemia

and/or myocardial infarction vs.

720 patients without evidence of


Study group B:

ELC observed in 26% of patients

200 patients undergoing coronary

with stenosis vs. 3.7% without



119 patients with >50% stenosis

of at least one major coronary

artery vs. 81 patients with normal



261 consecutive male patients

No different frequency of CHD in


with CHD undergoing coronary

the groups with and without ELC

angiography. Unclear

Both CHD and ELC increase with

classification of coronary artery




Table 4.6 Study groups: association of ear lobe crease (ELC) with acute myocardial infarction (AMI) and coronary heart disease (CHD); association of ELC with the conventional risk factors. A review of the literature 1974-2007—cont'd


Study groups

Association of ELC with AMI/CHD

Association of ELC with conventional risk factors

Lesbre (1987)

172 selected patients undergoing coronary arteriography with >75% stenosis of at least one major coronary artery

ELC observed in 52.3% of patients with stenosis vs. 12.8% without (P<0.001)

No prevalence of obesity, hypertension, diabetes mellitus, smoking and hyperlipidemia

Kenny (1989)

125 consecutive patients undergoing coronary angiography Severity of CHD graded according to the jeopardy score: (1) normal = 0; (2) mild disease = 2-6; (3) moderate to severe disease >6

No different angiogram score between patients with and without ELC

The severity of disease increases with age (P<0.02)

No prevalence in patients with ELC as regards gender, smoking, history of myocardial infarction, hypertension, family history of CHD, obesity

Verma (1989)

215 randomly selected patients to predict the correlation between ELC, ear-canal hair and CHD

Bilateral ELC significantly associated with documented CHD in the group 50-69 (P<0.001). The combination ELC + ear-canal hair is significantly associated with CHD (P<0.005)

Romagnosi (1990)

290 selected subjects undergoing a blood lipid profile examination: 166 with ELC, 124 without

Negative association between ELC and blood glucose, cholesterol, cholesterol HDL-LDL, tryglicerides, apolipoprotein A1 and B

Tranchesi (1992)

Group I: 1086 consecutive patients denying myocardial ischemic symptoms and hospitalized for other reasons Group II: 338 with documented CHD (>70% stenosis at angiography)

ELC was present in 28% of group I and 65% in group II (P<0.0001). When adjusted for age and sex the prevalence of ELC was still higher in patients with CHD than in the control group (P<0.001). Observed sensitivity of ELC for the diagnosis of CHD was 65%, the specificity 72%, the positive predictive value 42% and the negative predictive value 87%

Moraes (1992)

247 consecutive patients admitted to a general hospital Independent assessment of ELCs as running diagonally at 45° down the whole ear lobe

Significant correlation between ELC and CHD (P<0.001) No significant correlation between ELC and age and no prevalence in males vs. females

Negative association between ELC and hypertension, hyperlipidemia, peripheral vascular disease, stroke and smoking

Petrakis (1995)

625 white women studied for possible association of ELC with reproductive factors, use of contraceptives and menopausal estrogen, smoking, alcohol

Negative association between ELC and use of oral contraceptives, smoking and alcohol

Positive association with Quetelet index (weight/height2)

Kuon (1995)

670 patients undergoing coronary angiography studied for correlation between ELC and coronary diameter stenosis >70%

No correlation between ELC and coronary stenosis >70%

Positive association with age, overweight and hyperuricemia Negative association with diabetes, hypercholesterolemia, hyperlipidemia, family history of CHD, physical activity and smoking

Elliott (1996)

Prospective study on 264 patients of a coronary care unit followed up for 10 years

Primary outcome measure: time to cardiac event (coronary artery bypass graft, AMI or cardiac death)

Significantly different cardiac event-free survival rates for patients, with or without ELC: the highest for the group without ELC; the lowest for the group with bilateral ELC; intermediate for those with unilateral ELC

Miric (1998)

842 male patients <60 years hospitalized for the first nonfatal myocardial infarction vs. 712 patients hospitalized with non-cardiac diagnoses and with no clinical sign of CHD

Significant association between AMI and ELC in the first group

Positive association with baldness and thoracic hairiness Prevalence for males of the first group of hair graying under the age of 45

Motamed (1998)

1200 non-cardiac patients attending routine ENT clinic CHD assessed if angina or previous AMI in the patient's history

ELC observed in 48% of patients with positive history of CHD (P<0.001)

Sensitivity of ELC 48%; specificity 88%; positive predictive value 16%

Positive correlation with family history, hyperlipidemia and smoking

Negative correlation with hypertension and diabetes

Davis (2000)

1022 selected patients to determine whether ELC is a clinically useful sign of CHD or retinopathy in type 2 diabetes

Patients with ELC more likely to have CHD than those without an ELC (P<0.02), but the proportions with retinopathy were not significantly different in the two groups

Dharap (2000)

Observational study on 1576 healthy male and female Malay subjects randomly selected ELC studied in upright position Three different types of ELC:

I = incomplete crease,

II = complete but flat,

III = extensive crease

ELC present in 31.1% of males and 3.6% of females Significantly different incidence for all types of ELC (P<0.001)

Positive association with hypertension and smoking Negative association with diabetes, family history of CHD, cholesterol, triglycerides, obesity

Evrengul 415 consecutive patients

(2004) undergoing coronary angiography: 296 with at least a stenosis >70% in one of three major coronary arteries vs. 119 with normal arteries


Prevalence of ELC in patients with CHD 51.4% vs. 15.1% in the control group (P<0.001) Sensitivity of bilateral ELC for the diagnosis of CHD 51.3%; specificity 84.8%; positive predictive value 89.4%; negative predictive value 41.2%

Positive association with hypertension and smoking Negative association with diabetes, family history of CHD, cholesterol, triglycerides, obesity

Table 4.6 Study groups: association of ear lobe crease (ELC) with acute myocardial infarction (AMI) and coronary heart disease (CHD); association of ELC with the conventional risk factors. A review of the literature 1974-2007—cont'd


Study groups

Association of ELC with

Association of ELC with


conventional risk factors


3722 subjects from six primary

Prevalence of ELC in males

Significant association between


health care centers

(P<0.05) and in patients with

ELC grading and hypertension,

ELC grading: grade 0 = no crease

CHD (P<0.05)

diabetes and family history of

at all; grade 1 = any crease


<50% across the lobe; grade

2 = <100% across the lobe;

grade 3 = deep and prominent

crease across the whole lobe


130 apparently healthy subjects

Higher carotid IMT in subjects

Higher prevalence in these


examined by carotid ultrasound

with ELC compared to a group of

subjects as regards hypertension

to measure intima-media

age- and sex-matched non-ELC

and body mass index. No

thickness (IMT) of the right

subjects (P<0.0001)

prevalence as regards smoking,

common carotid artery

diabetes, family history of CHD,

cholesterol, triglycerides,

cardiovascular medical therapy

Table 4.7 Post-mortem studies on causes of death and severity of atherosclerosis (in coronary and in cerebral

arteries, and

in the aorta) in patients with ear lobe crease (ELC). A review of the literature 1976-2006


Cause of death and/or severity of

Association between ELC and

Association of ELC with


severity of atherosclerosis

conventional risk factors


Post-mortem study on 113

The mean amount of coronary


consecutive patients aged 40 or

sclerosis was higher in patients


with ELC than without (P<0.01)

Amount of coronary sclerosis

Patients with bilateral crease show

graded from 0 to 4 (1 = 25%,

a higher score than patients with

4 = 100%)

unilateral crease. As regards the

Degree of occlusion graded from

degree of occlusion, a trend was

0 to 4 (1 = 25%, 4 = 100%)

noted without significant



777 consecutive autopsies

Significant correlation between


performed for forensic reasons

ELC and 'significant

'Significant atherosclerosis' = one

atherosclerosis' (P<0.01)

or more of the three main coronary

Observed sensitivity 55%;

arteries with stenosis >75%

specificity 83%; positive

predictive value 42%;

negative predictive

value 90%


Post-mortem study on 303

Strong association between

Increased risk of


consecutive persons

cardiovascular causes of death

cardiovascular cause of death

The cardiovascular causes of

and ELC

in non-diabetic women with

death were classified in six groups:


ischaemic/hypertensive disease;

abdominal aneurysm; thoracic

aneurysm; calcific valvar

stenosis; cor pulmonale;



134 autopsies on males not

The extent of coronary and aortic

Positive association with


deceased from cardiovascular

atherosclerosis was higher in

hypercholesterolemia; negative

or cerebrovascular diseases

group III of ELC (P<0.01)

association with systolic and

Grading of atherosclerosis:

diastolic blood pressure

mean % of intimal area with

macroscopically atherosclerotic

lesions in the three coronary

arteries and in the thoracic and

abdominal aortic segments

ELC score groups:

Group I = no ELC; group

II = superficial ELC or not

completely crossing the ear

lobe; group III = deep, clear-

cut crease (Fig. 4.10)


Post-mortem study on 376

Significant association between


subjects over 40

severe coronary atherosclerosis and

Grading of coronary atherosclerosis

3-grade ELC

according to maximal luminal

In both sexes ELC grades 2 and 3


carried a significantly increased

grade I = mild (<50%); grade

relative risk of AMI as a cause of

II = moderate (50-75%); grade


III = severe narrowing (>75%).

Sensitivity of ELC for detecting

Grading of ELC:

severe coronary atheroma 62.1%

0 = no crease

for men and 69.2% for women;

1 = any degree <2

specificity 65.9% in men and

2a = diagonal crease >50% but

78.0% in women

less than 100%

2b = complete superficial crease

3 = complete deep crease


Post-mortem study on 520

ELC strongly correlated with CHD

Positive association with


consecutive patients

in both men and women

thickness of abdominal fat;

Assessment was made of cause of

(P<0.0001), but only in men with

negative association with BMI

death, of degree of atherosclerosis

sudden cardiac death (P<0.04)

in the coronary and cerebral

Strong correlation between ELC

arteries and in the aorta

and degree of atherosclerosis in

Heart, kidney and spleen weights

the coronary and cerebral arteries

were assessed as well as body mass

and in the aorta. Significantly

index (BMI) and thickness of

higher heart weight in ELC patients

abdominal fat


Baldness and excessive hair in the

Total sensitivity with regard to the

external acoustic meatus were also

severity of CHD 75%; specificity


64%; positive predictive value

68%; negative predictive

value 72%

76 Auricular acupuncture diagnosis

Ear Lob Coronairy

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  • Stanley
    What is franks sign ear?
    5 years ago
  • Ambessa
    Which ear lobe is crease in for franks sign?
    4 years ago
  • mariam
    What is a "grade 1" earlobe crease?
    3 years ago
  • nahand
    Is Frank sign on the ear reversible?
    2 years ago

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