Earlobe Creases: What Is the Significance?

Authors:
Melissa M. Helm and Stefanos Haddad, MD

Citation:
Helm MM, Haddad S. Earlobe creases: what is the significance?. Consultant. 2017;57(7):414.

A 90-year-old woman with a longstanding history of hypertension and nonexertional angina presented with bilateral earlobe creases. Her other medical conditions included Parkinson disease, a right bundle branch block, hypercholesterolemia, and osteoporosis.

Physical examination revealed a woman with stooped posture, an unsteady gait, and dyskinesia. Examination of her earlobes revealed bilateral diagonal creases (> 1 mm in depth) extending obliquely from the tragus toward the outer border of the earlobes and covering more than two-thirds of the length of the earlobes.

Answer on next page

Answer: Coronary artery disease

A 90-year-old woman with a longstanding history of hypertension and nonexertional angina presented with bilateral earlobe creases. Her other medical conditions included Parkinson disease, a right bundle branch block, hypercholesterolemia, and osteoporosis.

Physical examination revealed a woman with stooped posture, an unsteady gait, and dyskinesia. Examination of her earlobes revealed bilateral diagonal creases (>1 mm in depth) extending obliquely from the tragus toward the outer border of the earlobes and covering more than two-thirds of the length of the earlobes.

DISCUSSION

Diagonal earlobe creases (DELCs) extending from the tragus across the lobule of the ear were first recognized as a sign of coronary artery disease (CAD) by Frank in 1973¹ and are often referred to as the Frank sign. DELCs have been defined as a line covering at least one-third of the length between the tragus and the posteroinferior lobe edge.²

The simplicity and ready availability of this finding has stimulated considerable study since being first described. Although some studies have questioned the validity of this association, a recent meta-analysis found a 3.3-fold higher risk of CAD in individuals with DELCs compared with those without DELCs.^3,4 DELCs have also been independently associated with cardiovascular events such as ischemic stroke.² Recent angiographic studies support the association of CAD and DELCs.⁵

The pathophysiologic relationship between DELCs and CAD remains unclear, but the earlobes and the myocardium both are supplied by “end arteries” without collateral circulation, suggesting that anatomic constraints may be responsible for the common link between the two.⁶ Earlobe tissues might be subject to a diminished blood supply similar to myocardial tissues, leading to premature destruction of elastic fibers that manifests as DELCs.⁴

Although sun damage is associated with an increased risk of nonmelanoma skin cancer, DELCs are thought to have a vascular etiology rather than to result from actinic damage. Individuals with extensive photodamage have not been noted to have DELC. Similarly, smoking exacerbates damage of elastic tissue but has not been shown to be associated with DELC.

The diagnostic importance of DELCs is more significant when accompanied by traditional risk factors for CAD such as arterial hypertension, hyperlipidemia, dyslipidemia, elevated creatinine level, smoking, diabetes mellitus, and a family history of CAD.⁷ Further studies are warranted to confirm the relationship between DELCs and CAD and identify the causal relationship, but clinicians should be aware that DELCs may help identify patients who are at risk for CAD.

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Melissa M. Helm is a student in the Rensselaer Polytechnic Institute/Albany Medical College BS/MD Physician Scientist Program in Albany, New York.

Stefanos Haddad, MD, is a resident physician in the Department of Orthopaedic Surgery at the Albany Medical Center in Albany, New York.

REFERENCES:

1. Frank ST. Aural sign of coronary-artery disease. N Engl J Med. 1973;289(6):327-328.
2. Rodríguez-López C, Garlito-Díaz H, Madroñero-Mariscal R, et al. Earlobe crease shapes and cardiovascular events. Am J Cardiol. 2015;116(2):286-293.
3. Agouridis AP, Elisaf MS, Nair DR, Mikhailidis DP. Ear lobe crease: a marker of coronary artery disease? Arch Med Sci. 2015;11(6):1145-1155.
4. Lucenteforte E, Romoli M, Zagli G, Gensini GF, Mugelli A, Vannacci A. Ear lobe crease as a marker of coronary artery disease: a meta-analysis. Int J Cardiol. 2014;175(1):171-175.
5. Wang Y, Mao L-H, Jia E-Z, et al. Relationship between diagonal earlobe creases and coronary artery disease as determined via angiography. BMJ Open. 2016;6(2):e008558.
6. Tsunado T, Ito I, Katabira Y, Takahashi G. Histological study on the ear-lobe crease [in Japanese]. Hifu. 1982;24(3):352-360.
7. Hou X, Jiang Y, Wang, N, et al. The combined effect of ear lobe crease and conventional risk factor in the diagnosis of angiographically diagnosed coronary artery disease and the short-term prognosis in patients who underwent coronary stents. Medicine (Baltimore). 2015;94(26):e815.