Frank's Sign - Diagonal earlobe crease (DELC)
July 2, 2015
Figure 1. From (1) with permission.
In case you didn’t spot it here is another example:
Figure 2. Same patient with more obvious example on left ear.
1. What eponym is associated with this sign?
Answer: Frank’s – named after Dr Sanders T. Frank observed this crease in 20 patients with angina (2).
2. What are the associations?
After the initial identification in patients with coronary artery disease there have been larger studies documenting the presence of DELC in coronary artery disease (3), peripheral vascular disease (4) as well as cerebrovascular disease (5).
3. Do patients with DELC have increased risk of developing serious vascular disease?
Anecdotally, it is more often present in patients presenting to cardiology service who have had previous coronary bypass surgery. Just look at your patients ears next time you are on a cardiology ward!
However, the risk of developing vascular disease if noted in an asymptomatic individual is debated. In hospitalized patients, a recent meta-analysis showed a significant trend with multivariate analysis showed an association between DELC and cardiovascular events (odds ratio 1.45, 95% confidence interval [CI] 1.08 to 1.93, p [0.012], with a sensitivity and specificity of 43% and 70%) (6).
Notably these associations are not demonstrable in diabetic patients (7) and some studies suggest the association with any vascular disease is not significant (8).
4. What is the pathophysiology of this sign?
Again here theories vary, with no definitive answer. Some reports suggest micro-vascular disease in the middle ear lobe (9) which are end-artery territory. Others report shortened telomere length in Japanese patients with metabolic syndrome as a general pro-ageing and atherosclerotic mechanism (10). Interestingly this sign has also received attention in alternative medicine as the area of the earlobe affected was found to have higher electrical conductivity and tenderness in auricular reflexology (11).
5. Is there a grading system for the sign?
Yes, as it typical with many physical signs, observation is only the first step in accurate examination. When you find the sign, it has a grading system that has been linked to incidence of cardiovascular events based on length, depth, bilateralism, and inclination (6).
• Unilateral incomplete – least severe
• Unilateral complete
• Bilateral complete – most severe
Other classifications systems exist, but without the association with increased cardiovascular events (12):
• Grade 1 – wrinkling
• Grade 2a – superficial crease (floor of sulcus visible)
• Grade 2b – crease more than 50% across earlobe
• Grade 3 – deep cleft across whole earlobe (floor of sulcus not visible)
6. Do you know of any famous individuals with this sign?
The Roman emperor Hadrian in sculptures displayed across the world displays DELC. According to Wikipedia more recent famous people with DELC include George W. Bush and Steven Spielberg. Let’s hope they have gone to see their cardiologists recently.
Figure 3. Emperor Hadrian with right DELC (red arrow) at British Museum.
Figure 4. Steven Spielberg with left DELC (red arrow). Photograph: Gabriel Bouys/AFP/Getty Images
1. Friedlander AH, López-López J, Velasco-Ortega E. Diagonal ear lobe crease and atherosclerosis: a review of the medical literature and dental implications. Med Oral Patol Oral Cir Bucal [Internet] 2012 [cited 2015 Jun 24];17(1):e153–9. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3448193&tool=pmcentrez&rendertype=abstract
2. Frank ST. Aural sign of coronary-artery disease. N Engl J Med [Internet] 1973 [cited 2015 Jun 28];289(6):327–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/4718047
3. Evrengül H, Dursunoğlu D, Kaftan A, et al. Bilateral diagonal earlobe crease and coronary artery disease: a significant association. Dermatology [Internet] 2004 [cited 2015 Jun 24];209(4):271–5. Available from: http://www.karger.com/Article/FullText/80847
4. Korkmaz L, A X011f Ac MTXK, Acar Z, et al. Earlobe Crease May Provide Predictive Information on Asymptomatic Peripheral Arterial Disease in Patients Clinically Free of Atherosclerotic Vascular Disease. Angiology [Internet] 2014;65(4):303–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23449604
5. Çelik Ş, Erdoǧan T, Gedikli Ö, Kiriş A, Erem C. Diagonal ear-lobe crease is associated with carotid intima-media thickness in subjects free of clinical cardiovascular disease. Atherosclerosis 2007;192(2):428–31.
6. Rodríguez-López C, Garlito-Díaz H, Madroñero-Mariscal R, et al. Earlobe Crease Shapes and Cardiovascular Events. Am J Cardiol [Internet] 2015;116(2):286–93. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0002914915011200
7. Davis TM, Balme M, Jackson D, Stuccio G, Bruce DG. The diagonal ear lobe crease (Frank’s sign) is not associated with coronary artery disease or retinopathy in type 2 diabetes: the Fremantle Diabetes Study. Aust N Z J Med 2000;30(5):573–7.
8. Cheng TO. More research needed on the association between diagonal earlobe crease and coronary artery disease. Arch Intern Med [Internet] 2000 [cited 2015 Jun 29];160(15):2396–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10927744
9. Shoenfeld Y, Mor R, Weinberger A, Avidor I, Pinkhas J. Diagonal Ear Lobe Crease and Coronary Risk Factors. J Am Geriatr Soc [Internet] 1980 [cited 2015 Jun 29];28(4):184–7. Available from: http://doi.wiley.com/10.1111/j.1532-5415.1980.tb00514.x
10. Higuchi Y, Maeda T, Guan J-Z, Oyama J, Sugano M, Makino N. Diagonal earlobe crease are associated with shorter telomere in male Japanese patients with metabolic syndrome. Circ J 2009;73(2):274–9.
11. Kwai-Ping Suen L, Lau Y, Ma H, Lai K, Holroyd E. Predictive Value of Auricular Diagnosis on Coronary Heart Disease. Evidence-Based Complement Altern Med [Internet] 2012;2012:1–9. Available from: http://www.hindawi.com/journals/ecam/2012/706249/
12. Ryder REJ, Mir MA, Freeman EA. An Aid to the MRCP Short Cases [Internet]. John Wiley & Sons; 2009 [cited 2015 Jun 29]. Available from: https://books.google.com/books?id=w3Cqrf-1F7YC&pgis=1
Watch this video to get a first-person perspective of the Examination of the Hand with Abraham Verghese.
In this session, we shared our experiences with teaching the physical exam at the bedside. Our participants got into groups and came up with their own bedside teaching example to share with everyone.
It’s important to understand what diseases are associated with a given type (test) of tremor.