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Requests for reprints should be addressed to Konstantinos C. Christodoulou, MD, Laboratory of Anatomy, Medical School, Democritus University of Thrace, Domnas Visvizi 34, Pylaia, Thessaloniki P.C. 55534, Greece. E-mail address:
A 72-year-old man, non-smoker, with a medical history of hypertension, hypercholesterolemia, atrial fibrillation, and a myocardial infarction 15 years prior, presented to the Emergency Department complaining about difficulty speaking and left-hand weakness of 6-hour duration. Apart from an elevated blood pressure, at 170/100 mm Hg, physical examination revealed dysarthria, accompanied by left brachial monoplegia and hypoesthesia. A bilateral earlobe wrinkle extending obliquely and backward, at a 45o angle, from the tragus to the edge of the auricle (Frank's sign) was observed (Figure 1A). Subsequently, the patient underwent an urgent cranial computed tomography scan that showed a right frontal lobe ischemic infarction, with ipsilateral expansion to the Island of Reil and the external capsule, a minor right parietal lobe subcortical ischemic infarction (Figure 1B and C), along with bilateral calcifications in the intracranial internal carotid artery segment. The patient was then referred to the Neurology Department for further investigation and treatment.
In 1973, the American physician Sanders T. Frank first described the diagonal earlobe crease, which was later named “Frank's sign” in his honor, stressing its significance as a precursor of coronary artery disease (CAD).
attempted to document all possible ear creases in patients with existing CAD, introducing a scoring system based on their findings. Eventually, 4 types of ear wrinkles were noted: 1) crossing crease originated from ear hole, 2) crossing crease not originated from ear hole (typical Frank's sign), 3) vertical creases dividing earlobe and face, and 4) vertical creases on the face side, were most common among patients with high complexity CAD. Thus, a statistical significance was established between SYNTAX score and Frank's sign score.
Recently, Frank's sign has been related to cerebrovascular diseases, especially ischemic strokes;
Nevertheless, the concomitant presence of carotid intima media thickness and Frank's sign in otherwise asymptomatic patients with subclinical CAD may serve as an indicator for long-term atherosclerosis.
report that Frank's sign is commonly encountered in patients with pre-existing risk factors for cerebrovascular diseases such as hypertension and history of myocardial infarction as in the herein presented patient, or even diabetes mellitus.
As this ear wrinkle is easily detected during physical examination, Frank's sign could be considered as a potential screening test for CAD and ischemic strokes. However, it is crucial to always consider the existence of other “key” risk factors in order not to be led to misassumptions about Frank's sign and its prognostic significance in cardiovascular disease.