Frank’s Sign

heart9heart7Above is Frank’s Sign, but it has nothing to do with this week’s Hearing International.   This week’s discussion is also not about any of the famous Franks that you know, such as “Ol’ Blue Eyes” Frank Sinatra, “heavy metal Frank”,  Frank Zappa,heart4  “designer Frank”,  Frank Lloyd Wright, or even “Football Frank”, Frank Gifford.  heart6heart5

Our story this week is about an interesting portion of the auditory anatomy with which all audiologists are all familiar, the Auricle or Pinna.

Early Chinese references suggest that the ear is related to all parts of the human body and internal organs and that all meridians converge at the ear, specifically at the Auricle.  According to Chinese medicine references, there are some 91 acupoints on the auricle, each relating to a part or organ of the body.  And, in their opinion, when changes are noted in the auricle they can signal what’s happening in other partheart1s of the body.  Similarly, when appropriate stimulation is presented to these 91 special areas of the auricle, it may cause changes in those areas of the body sympathetic  to that particular stimulation.  The ear, as a diagnostic and treatment area, was first mentioned in the earliest Chinese medical book, Yellow Emperor’s Classics of Internal Medicine, published more than 2,000 years ago.  To the Chinese, the ear has a reflexive property which means that physical attributes may appear on the auricle when certain disorders exist in the body.

Fast Forward to 1973

 Since its first description by Sanders T. Frank, M.D.,  an American Pulmonologist, in the New England Journal of Medicine in 1973, the presence of the diagonal earlobe crease heart2(ELC) either unilaterally or bilaterally has been recognized as a possible marker of coronary artery disease (CAD).  Subsequent studies seem to confirm that the ELC (or Frank’s Sign) may be a possible predictor of CAD independent of age, cholesterol, blood pressure, or smoking status.  On the other hand, several studies found no correlation between ELC and CAD and suggest that it is simply a marker of advancing age.  Over 50 papers have been published regarding this physical diagnosis sign and, for almost four decades, controversy has raged over its utility. Such attributes include variations in shape, color, size, and sensation; appearance of papules, creases, and edema; and increased tenderness or decreased electrical conductivity.  Is the ELC a clinically useful predictor of CAD?  a review of the studies in the area would suggest a sound maybe and some of these have additionally linked Frank’s Sign to acquired hypertension, heart disease, and diabetes.

For example, Evrungu (2004) published in Dermatology reported that the presence of ELC has a high CHD predictive value.  While it seems too simple to consider these earlobe creases seriously, they probably should not be dismissed too lightly as they fall into the surprisingly large category of “weird signs” that are possibly indicative of heart disease.  As shown in the pictures above, earlobe crease (ELC) is a line running diagonally from the bottom of the ear opening to the ear’s lower tip. There are also studies that discuss an ear hair correlation with heart disease are probably false, but the ELC or Franks Sign’s status as portent of doom has a bit of empirical evidence:

  • A Swedish study of 520 autopsies found ELC had a “positive predictive value” for coronary artery disease of 68% — 80% in those under 40.
  • A Turkish study found ELC was a higher risk factor for heart disease than diabetes, family history of cardiovascular trouble, or smoking.
  • Of 340 patients admitted to the Montreal Heart Institute, 91% of those with ELC had heart disease versus only 61% of those without.
  • An Irish study of 247 patients found ELC had a predictive value of 71% for heart disease, showing what statisticians call low sensitivity but high specificity.

While these and other studies seem to confirm ELC or “Frank’s Sign” as indicative of heart disease and other maladies, most physicians place little stock in it, yet are careful NOT to ignore it.  While it could be bunk, there may be something to its presence.

heart12And Just when we did not Believe…..

Publius Aelius Hadrianus better known as Hadrian, Emperor of Rome (113-138, BC) was a traveler, warrior, and lover of all things Greek. At age 60, Hadrian fell ill.  He developed progressive edema and episodic epistaxis, fell into a depression soothed by rich food and drink, and succumbed within 2 years. The exact cause of Hadrian’s death – whether heart failure, glomerulonephritis, or even hereditary hemorrhagic telangiectasia – has been a topic of debate among paleopathologists.  Not until 1980 was a crucial clue found: He was sculpted in stone busts with a deep diagonal crease memorialized in both earlobes….Hmmmm…..Could it have been heart disease?


Last but NOT Least…..

Another famous person who has ELC is former US President George W. Bush.  The Time Magazine cover of Dec. 1, 2003 confirms an ear lobe crease on the right and  suggests the presence of hair in the ear canal (also a controversial sign to most physicians). It has been reported that the combination of ear lobe crease and hair in the ear canal is EVEN MORE predictive of coronary artery disease than either alone.   Let’s just wait that one out and see what happens!


About Robert Traynor

Robert M. Traynor is a board certified audiologist with 45 years of clinical practice in audiology. He is a hearing industry consultant, trainer, professor, conference speaker, practice manager, and author. He has 45 years experience teaching courses and training clinicians within the field of audiology with specific emphasis in hearing and tinnitus rehabilitation. Currently, he is an adjunct professor in various university audiology programs.