Indian Journal of Otology

: 2020  |  Volume : 26  |  Issue : 1  |  Page : 9--14

A study on the prevalence of diagonal earlobe crease in patients with cardiovascular disease and diabetes mellitus

Ehrlson De Sousa1, Vinson Louis Gonzaga Fernandes1, Harish Chander Goel1, Kanhai Naik1, Nina Margarida de Gouveia Pinto2,  
1 Department of ENT, Goa Medical College, Bambolim, Goa, India
2 Department of Medicine, Goa Medical College, Bambolim, Goa, India

Correspondence Address:
Dr. Ehrlson De Sousa
B-2/F4, Sabnis Park, Alto Porvorim Bardez, Goa


Background: The diagonal ear lobe crease also known as Frank's sign is a diagonal crease in the ear lobe that extends from the tragus across the lobule to the posterior edge of the auricle. There have long been postulates of the association of Frank's sign with cardiovascular disease, diabetes mellitus and there have been studies that have said that Frank's sign is a mark of cardiovascular disease but have not linked it to the severity of the disease. Methods: In our study we aim to assess the prevalence of Frank's sign in individuals with coronary artery disease and evaluate its correlation with its severity while also seeing if the correlation exists with diabetes mellitus, laterality of the sign and hair in the external auditory canal in our setting of a tertiary care hospital amongst a sample of 152 patients with proven ischemic heart disease. Clinical data included age, gender, presence of Diabetes mellitus, severity of IHD as per angiography, grade of Frank's Sign, presence of hair in the canal and laterality of Franks sign. Results: Franks sign was more often seen around the age group of 51 to 70 years and though it was seen more often in the male population this was not a statistically significant correlation. 98 patients with IHD (64.47%) had Franks sign. Of these, 50 (51%) had Diabetes Mellitus. The presence of bilateral Frank's sign was more often associated with IHD and this was seen to be statistically significant. So also, presence of hair in the canal was shown to be having a positive Frank's sign more often than not. While severity of IHD varied almost directly with grade of Frank's sign it was not a statistically significant correlation. Conclusion: Therefore, we may presume that the presence of the DELC correlates to some extent correlate with ischemic cardiovascular disease it does more so when bilateral. Though many patients also have diabetes mellitus, the co-existence was not found to have statistical significance and larger studies will be required to prove its usefulness in this regard.

How to cite this article:
Sousa ED, Fernandes VL, Goel HC, Naik K, Pinto NM. A study on the prevalence of diagonal earlobe crease in patients with cardiovascular disease and diabetes mellitus.Indian J Otol 2020;26:9-14

How to cite this URL:
Sousa ED, Fernandes VL, Goel HC, Naik K, Pinto NM. A study on the prevalence of diagonal earlobe crease in patients with cardiovascular disease and diabetes mellitus. Indian J Otol [serial online] 2020 [cited 2021 May 15 ];26:9-14
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Full Text


In modern-day medicine, it is increasingly becoming routine practice to utilize large batteries of investigations and radiological imaging among other aides in coming to diagnoses with progressive generations showing less enthusiasm in the old-fashioned reliance upon a thorough, detailed clinical history and an astute detailed examination at the bedside or outpatient clinic or even in the emergency room.

Subtle clinical signs have long since played a role in suspicion of many a diagnosis and pathognomonic for few. Here, we would look at one such subtle, yet obscure sign named after an American physician Sanders T. Frank who first proposed it in 1973.[1] He essentially described it as a deep diagonal crease in the earlobe that extends across the lobule right from the tragus to the posterior edge of the lobule, at an angle of around 45°. It has also been referred to as the diagonal earlobe crease (DELC) [Figure 1].{Figure 1}

It was in this study that Dr. Sanders proposed a correlation between the DELC and cardiovascular disease (CAD); he also took to analyze its laterality and the presence of hypercholesterolemia, diabetes mellitus, and other risk factors for CAD. A correlation was found between coronary artery disease which was significant enough to warrant further investigation into this sign.

There have in fact been several studies conforming to this hypothesis[1],[2] and have also utilized CT to prove the presence of coronary atherosclerosis. The sign has since garnered much interest, and numerous studies that correlate it to the presence of ischemic heart disease, cerebrovascular disease, diabetes mellitus, and peripheral vascular disease have since been conducted.

The present study examines the association between Frank's sign and the development of ischemic CAD, to see if it correlates well with severity and to note if it is also associated with hypertrichosis in the ear and diabetes mellitus in the sample of 152 patients present in the cardiology wards of our tertiary level institute.

 Materials and Methods

The study was conducted in a retrospective observational fashion on patients already diagnosed, admitted, and undergoing treatment for coronary artery disease in the cardiology and cardiovascular and thoracic surgery wards of Goa Medical College for Ischemic Coronary Artery Disease. Informed consent was obtained in all cases. The study was approved by the Institutional Ethics Committee.

History (including past medical and surgical history) and physical examination along with data on laboratory results and coronary angiography were collected in each case and compiled.

The presence of DELC was checked in both ears. If present, it was graded as per the grading system shown in [Table 1].[3]{Table 1}

The data thus compiled included the name, age, gender, laterality, grade of Frank's sign, presence of Type 2 diabetes mellitus, and severity of ischemic heart disease (as per number of vessels involved, assessed using coronary angiography).

Data obtained thus were compiled and analyzed using SPSS (IBM, Armonk, NY, USA) with the Student's t-test and Chi-square tests.


The study was conducted among 152 patients admitted and undergoing treatment in the cardiology and cardiothoracic and vascular surgery department wards in a tertiary care hospital. It was a retrospective observational study. Informed consent was obtained in all cases for inclusion in this study. Of the 152 patients with known CAD, it was seen that 98 patients had a positive DELC (64.47%).


It was seen that among patients with CAD, the DELC was more likely to be prevalent among individuals between 51 and 70 years of age (See [Table 2] and [Figure 2]).{Table 2}{Figure 2}


It was seen that DELC was more commonly seen among male patients, i.e., 69 (70.04%), when compared to female patients with CAD 29 (29.59%) (See [Table 3] and [Figure 3]).{Table 3}{Figure 3}


It was seen that majority of the cases of ischemic CAD had bilateral Frank's sign positivity to the tune of 94.9%, and this result was statistically significant with P< 0.001 (See [Table 4] and [Figure 4]).{Table 4}{Figure 4}

Excessive hair (hypertrichosis) in the external auditory canal

Incidentally, it was noted that excessive hair in the external auditory canal was present in 86 (56.57%) cases. It was also noted that the presence of this sign was more often seen than not in cases of DELC with coronary vascular disease. This was seen to be statistically significant with P= 0.001 (See [Figure 5] and [Table 5]).{Figure 5}{Table 5}

Ischemic heart disease and its severity

While it was seen that 98 patients with CAD had DELC, cases with DELC in a higher grade were, however, associated with a worse outcome. Double- and triple-vessel disease patients more often had DELC, and this correlation was statistically significant with P< 0.001.

Diabetes mellitus Type 2

We see that of the 152 patients, 73 were diabetic. Of these, 50 patients were Frank's sign positive, i.e., 68%. However, due to the smaller sample size, we were unable to establish statistical significance to this result.


It can thus be said that while DELC was quite prevalent among patients with ischemic heart disease, its prevalence was not as significant as to deem it pathognomonic for the same, through our study.


Soon after Dr. Sanders proposed the DELC, numerous theories were propagated to its development. Initially, it was suggested that poor blood supply to the earlobe resulted from atherosclerotic changes as the earlobes are supplied by end arteries.[4]

Another theory is that there is loss of elastin with rupture of elastic fibers in patients with atherosclerosis and ischemic vascular disease, leading to loss and degeneration of elastin fibers. A biopsy from the earlobes of 12 patients with this sign found that there were tears in the elastic fibers of the lobule and thickening of the arterial wall.[5]

Another study was done on Japanese men with DELC who were suffering from metabolic syndrome. In these men, it was seen that shorter telomeres were present, which are indicators of accelerated aging and an accelerated atherosclerotic process.[6]

Several other theories have in fact been put forward including an increased prevalence of coronary vascular disease among the aging population, an accelerated aging process, common genetics to aging and the DELC, acquired anatomic changes due to specific sleeping habits, and lying positions in patients with heart disease causing pressure on the earlobe and yet, another theory that there is common innervation of the auricle and the heart through the vagus nerve.[7]

Frank's sign and ischemic heart disease

Many studies have considered Frank's sign as an independent risk factor for coronary heart disease. After Frank, who described this finding in a patient with ischemic heart disease, it was suggested to add Frank's sign to the classic risk factors (Type 2 diabetes mellitus, hypertension, and smoking) to the list of risk factors of ischemic heart disease.[1]

In a survey describing 421 patients who experienced myocardial infarction and 421 healthy participants who were recruited as the control group, Frank's sign was found in 77% of the patients with myocardial infarction, and only 40% of the healthy participants had Frank's sign quite similar to what was seen in our study. A statistically significant association was even stronger in patients with diabetic retinopathy, hypertension, and patients of Ashkenazi descent in this study.[5]

A study that evaluated the association between coronary artery disease and Frank's sign using coronary computed tomography found that it was present in 71% of the patients with documented coronary artery disease. This study demonstrated that Frank's sign was a statistically significant predictor of the presence of coronary artery disease.[8] In a similar fashion, we have seen that coronary angiography also correlates with the Frank's sign, especially in terms of severity of disease, with two- and three-vessel disease almost always being Frank's sign positive.

In 2011, a review was published describing Frank's sign as an indicator of ischemic heart disease. Among 956 patients with ischemic heart disease who underwent coronary intervention catheterization, the prevalence of Frank's sign was strongly associated with ischemic heart disease, mainly in patients with who had more than four risk factors. Patients who had Frank's sign in both ears had an increased rate of cardiovascular complications after coronary catheterization.[9]

The association between Frank's sign and CADs was also studied in 2015, with 89.6% likelihood of Frank's sign and coronary artery disease or peripheral vascular disease both representing the progressive atherosclerotic process.[10]

Some studies have described Frank's sign as a marker of CAD but not linked to the severity of the condition. We, however, see that its strong correlation with triple-vascular disease indicates a good correlation with severity of coronary artery disease.

Frank's sign and other vascular disorders

Frank's sign has also been correlated with the presence and development of peripheral vascular disease. Arterial stiffness has been proposed as a tool by “the European Society of Hypertension/European Society of Cardiology” for the evaluation of subclinical damage to target organs and is considered a measure of atherosclerosis.[11]

In 2013, a study examined the relationship between Frank's sign and vascular stiffness by measuring the “cardio-ankle vascular index,” which reflects the stiffness of blood vessels. In patients with Frank's sign, the cardio-ankle vascular index was higher with a statistically significant difference compared with patients without Frank's sign.[12]

Korkmaz et al. studied 253 patients without a peripheral vascular disease. In these patients, ankle-brachial index was measured. In patients with Frank's sign, a lower ankle-brachial index was measured compared to patients without Frank's sign. Multivariate analysis of the data found that Frank's sign and advanced age were independent factors for abnormal ankle-brachial index. They found increased incidence of Frank's sign associated with increasing severity of the disease.

There have also been reported cases of Frank's sign assisting in the diagnosis of cerebral infarcts. A link between Frank's sign and premature aging and the metabolic syndrome has also been hypothesized.

Frank's sign and diabetes mellitus

Although we see that it was present with some majority, it was not entirely significant and there are studies done that also concur.

Davis et al. did so in over 1000 patients and saw that the ELC is of little value as a sign of the presence of diabetic vascular complications.[13]

Bilateral Frank's sign

In our study, we see that bilateral Frank's sign correlates well with the presence of CAD due to a low P value.

A similar study was done on 415 patients for bilateral ELC, angiographic evidence of CAD, and coronary risk factors and has seen that the presence of bilateral DELC was significantly associated with CAD and coronary risk factors. The bilateral DELC was an important dermatological indicator of CAD, and it might be a useful diagnostic tool in the clinical examination of patients.[14]

Hair in the external auditory canal

Many patterns of hair have been observed in relation to CAD. One such is the development of hair in the external auditory canal, also including those with terminal hair on the tragus or antitragus.

As can be seen, it correlates well with the DELC and is almost always present together.

Androgens which are most likely responsible for the development of this feature are also probably responsible for atherosclerotic changes, and long-term exposure may thus be responsible for either feature.[14]

We see that a majority of patients with CAD indeed possessed this trait (57%), and it is strongly linked with DELC.


Therefore, from our discussion, it is evident that although Frank's sign is seldom discussed or used as a diagnostic aid, literature would suggest that in conjunction with other markers of ischemic heart disease and atherosclerosis, Frank's sign should be seen as an adjunct to diagnosing suspected ischemic heart disease and its presence may identify patients at increased risk of CAD.

Its presence in a patient over the age of 60 should rouse suspicion and aid clinical decision-making in relation to the choice of future investigations and management. However, it should not be seen a pathognomonic finding and as such should be considered alongside the findings of a full physical examination and relevant investigations.

However, this is not entirely so with DM although many cases present with the same. Its presence should be looked for routinely and it can be of help in diagnosis and therefore propose adequate investigation and management.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Frank ST. Aural sign of coronary-artery disease. N Engl J Med 1973;289:327-8.
2Gulsin GS, Clement KD, Anglim N. Frank's Sign as a marker of coronary artery atheroslcerosis. J Cardiol Clin Res 2014;2:1032.
3Patel V, Champ C, Andrews PS, Gostelow BE, Gunasekara NP, Davidson AR, et al. Diagonal earlobe creases and atheromatous disease: A postmortem study. J R Coll Physicians Lond 1992;26:274-7.
4Korkmaz L, Aǧaç MT, Acar Z, Erkan H, Gurbak I, Kurt IH, et al. Earlobe crease may provide predictive information on asymptomatic peripheral arterial disease in patients clinically free of atherosclerotic vascular disease. Angiology 2014;65:303-7.
5Shoenfeld Y, Mor R, Weinberger A, Avidor I, Pinkhas J. Diagonal ear lobe crease and coronary risk factors. J Am Geriatr Soc 1980;28:184-7.
6Higuchi Y, Maeda T, Guan JZ, Oyama J, Sugano M, Makino N, et al. Diagonal earlobe crease are associated with shorter telomere in male Japanese patients with metabolic syndrome. Circ J 2009;73:274-9.
7Murray AR, Atkinson L, Mahadi MK, Deuchars SA, Deuchars J. The strange case of the ear and the heart: The auricular vagus nerve and its influence on cardiac control. Auton Neurosci 2016;199:48-53.
8Agouridis AP, Elisaf MS, Nair DR, Mikhailidis DP. Ear lobe crease: A marker of coronary artery disease? Arch Med Sci 2015;11:1145-55.
9Nazzal S, Hijazi B, Khalila L, Blum A. Diagonal earlobe crease (Frank's sign): A predictor of cerebral vascular events. Am J Med 2017;130:1324.e1-0000.
10Glavic J, Cerimagic D, Lovrencic-Huzjan A, Vukovic V, Demarin V. Frank's sign as a risk factor for cerebrovascular disease. Atherosclerosis 2008;196:477-8.
11Mancia G, Grassi G. The New European Society of Hypertension/European Society of Cardiology (ESH/ESC) Guidelines. Ther Adv Cardiovasc Dis 2008;2:5-12.
12Sun CK. Cardio-ankle vascular index (CAVI) as an indicator of arterial stiffness. Integr Blood Press Control 2013;6:27-38.
13Davis 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;30:573-7.
14Evrengül H, Dursunoǧlu D, Kaftan A, Zoghi M, Tanriverdi H, Zungur M, et al. Bilateral diagonal earlobe crease and coronary artery disease: A significant association. Dermatology 2004;209:271-5.