A 43-year-old male with a history of hypertension and chronic kidney disease, stage 3, presented with chief complaints of fever, chills, lower extremity redness, and pain. On examination, he was hemodynamically stable with findings consistent with bilateral lower extremity cellulitis. A wrinkle-like line extending in the earlobes extending backward from the tragus at an angle of 45° was observed bilaterally. Laboratory evaluation did not reveal hyperlipidemia, but on further questioning he gave history suggestive of angina. After resolution of the cellulitis, the patient was discharged home with instructions to follow up with his primary care doctor for cardiac work up.
Diagonal ear lobe crease (also known as Frank’s sign) has been traditionally considered as a surrogate marker of coronary and carotid artery atherosclerosis (1). It was first associated with coronary artery disease in an article by Frank published in 1973 (2). Alternative hypotheses such as coincident association between aging changes and atherosclerosis, anatomic peculiarity, or a result of a particular way of sleeping have also been proposed for diagonal ear lobe creases (3). Although controversies remain, a recent study by Shmilovich et al. found that it is associated not only with the presence of coronary atherosclerosis but also with its extent and severity (4). It has been postulated that ear lobe and myocardium are supplied by the same genetically originated end arterioles and thus share a common pathway (5).
In conclusion, although controversies exist, the presence of diagonal ear lobe crease should prompt clinicians to evaluate patients for coronary or carotid atherosclerotic disease, especially when there are other concurrent risk factors for atherosclerosis.
The arrow points to Frank’s Sign, an oblique crease running from the tragus back towards the rear edge of the ear lobule.
References
- 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. 2012;17(1):e153–9. doi: 10.4317/medoral.17390. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Frank ST. Ear-crease sign of coronary disease. N Engl J Med. 1977;297(5):282. doi: 10.1056/NEJM197708042970516. [DOI] [PubMed] [Google Scholar]
- 3.Gutiu IA, Galeţescu E, Gutiu LI, Răducu L. Diagonal earlobe crease: A coronary risk factor, a genetic marker of coronary heart disease, or a mere wrinkle. Ancient Greco-Roman evidence. Rom J Intern Med. 1996;34(3–4):271–8. [PubMed] [Google Scholar]
- 4.Shmilovich H, Cheng VY, Rajani R, Dey D, Tamarappoo BK, Nakazato R, et al. Relation of diagonal ear lobe crease to the presence, extent, and severity of coronary artery disease determined by coronary computed tomography angiography. Am J Cardiol. 2012;109(9):1283–7. doi: 10.1016/j.amjcard.2011.12.024. [DOI] [PubMed] [Google Scholar]
- 5.Evrengül H, Dursunoğlu D, Kaftan A, Zoghi M, Tanriverdi H, Zungur M, et al. Bilateral diagonal earlobe crease and coronary artery disease: A significant association. Dermatol Basel Switz. 2004;209(4):271–5. doi: 10.1159/000080847. [DOI] [PubMed] [Google Scholar]