Frank sign

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FRANK SIGN

Frank sign (from Dr Sanders T. Frank who first observed this crease in 20 patients with angina - the chest pain when the heart doesn’t get enough blood.) is the presence of a crease in the ear lobes (ELC) that extends diagonally 45° backwards from the tragus to the rear edge of the auricule.

It is hypothesized to be a dermatologic predictor of coronary artery disease (CAD) (ischemic heart disease and myocardial infarctions) and a useful diagnostic physical sign in adults less than 60 years of age. ELC is also associated with higher risk of major adverse cardiac events in patients with known CAD.

ELC may also be a marker of premature aging, and is associated with carotid intima-median thickness, a marker of subclinical atherosclerosis in subjects free of clinical cardiovascular disease.

About the pathophysiology of this sign, there is no definitive answer because the etiologic basis of ELC is not fully understood. Some reports suggest micro-vascular disease, others postulate that circulating free radical oxidative stress and weakening of elastic fibers may be potential explanation to the dermatological changes, reflecting a similar pathology in weakened coronary arteries.

Frank sign is independent of traditional CAD risk factors (such as serum lipids, diabetes mellitus, hypercholesterolemia, arterial hypertension, obesity and smoking status) and it is not correlated with the gravity of coronary disease. Of course its absence does not permit in any way to exclude the diagnosis of coronary disease.

The sensitivity (the ability of the test to correctly identify those patients with the disease) of Frank's sign reaches about 75 p. cent, its specificity (the ability of the test to correctly identify those patients without the disease) is about 57 p. cent.

In an asymptomatic population with a low prevalence of coronary artery disease it appears to be of limited value in predicting obstructive coronary artery disease. However, it may identify a subset of patients prone to early ageing and to the early development of coronary artery disease, whose prognosis might be improved by early preventive measures.

There is a grading system for the Frank sign linked to incidence of cardiovascular events based on length, depth, bilateralism, and inclination:

Unilateral incomplete – least severe
Unilateral complete
Bilateral complete – most severe

Another classification, without the association with increased cardiovascular events, is:

Grade 1 – a small amount of wrinkling on the earlobe
Grade 2a – superficial crease (floor of sulcus visible) across the earlobe
Grade 2b – crease more than 50% across the earlobe
Grade 3 – deep cleft across whole of the eralobe (floor of sulcus not visible)

Of course observation is only the first step in accurate examination.

About famous individuals with this sign, Publius Aelius Hadrianus Augustus, the Roman emperor Hadrian, remembered today for being one of the “good emperors,” and for building his eponymous wall in Britain. He died of a misterious illness. He displays right ELC in the sculpture at British Museum in a bust at the Athens National Museum and in other three additional busts of Hadrian in Greece and Italy:all exhibited the same sign.

Shortly after his 60th birthday, Hadrian fell ill. He had been long-plagued by epistaxis (nosebleeds), time by time more severe. The great loss of blood made Hadrian consumptive and edematous till to death.

In conclusion:

Frank's sign is a diagonal earlobe crease that extends 45° backwards from the tragus to the auricle,
It is hypothesized to be a predictor of atherosclerotic disease.
There is a significant association of it with increased risks of ischemic heart disease and myocardial infarctions.
It is independent of traditional CAD risk factors.

It is a useful diagnostic physical sign in adults less than 60 years of age.
It may identify a subset of patients prone to early ageing and to the early development of coronary artery disease.