He referred two clinical cases with skin alterations of the lung area.² The first was a patient with severe non-responding eczema of the buttocks, genitals and face. Furthermore Nogier identified a small area of eczema corresponding to the lung; this led him to suspect a tubercular origin for the eczema which afterwards responded well to the appropriate treatment. The second case was that of a patient who had been affected for several years by pneumothorax; the corresponding lung area was well recognizable on inspection because it was creased and yellowish.

The French lung area corresponds on the whole to the Chinese one (CO14 Fei); nevertheless, in the latter the lung has a larger representation, occupying almost the whole inferior concha. The dimensions of this area are proportional to the importance of the lung in traditional Chinese medicine (TCM); the indications for treatment are cough, chest congestion and hoarseness, but also skin disorders such as acne, itching and urticaria. Other indications are constipation and control of the abstinence syndrome as described in Chapter 1.

Even though Nogier realized the importance of skin alterations on the auricle he did not perform any systematic study nor did he invite his pupils to focus on this subject.

THE CHINESE CONTRIBUTION TO THE INSPECTION OF THE OUTER EAR

As noted in Chapter 1, the application of the principles of TCM to ear acupuncture by Chinese therapists favored an original development of this discipline. If we consider the four different diagnostic methods proposed by TCM, besides pulse and tongue diagnosis, we find examination of the patient at the top, followed by the interview, auscultation and smelling and palpation of the body. It is not by chance that palpation has been ranked last; an aphorism written by the famous physician Pien Chueh in his book Nan Jing (Difficult Classic) was:

the physician who knows his patient’s condition through inspection examining him is a genial physician; the physician who understands his condition through auscultation and smelling is a saint; the physician who recognizes his condition through palpation is a second-rate physician.

There is no part of the body which was not the object of observation by TCM. It is plausible, therefore, that the outer ear was included in this thorough examination during past centuries.

Nevertheless, observations on the auricle were scanty compared to those on the tongue and the other parts of the face. Among signs found in Chinese classical textbooks are those related, for example, to the color of the helix ³ (Table 4.1).

Table 4.1 Some explanations of abnormal color of the helix according to traditional Chinese medicine (TCM) (after Maciocia ³)

Color of the helix	Tone	Energetic explanation according to TCM
Pale	Bright	Yang deficiency
Pale	Dull	Blood deficiency
Pale	Deep and ‘thick’	Qi deficiency with Phlegm
Yellow	Bright	Damp-Heat; Heat predominates
Yellow	Dull	Damp-Heat; Dampness predominates
Greenish		Blood stasis from Heat
Greenish	Dark	Kidney-Yin deficiency
Bluish		Blood stasis from Cold
Red		Heat in the Lung and/or in the Heart
Red	Floating	Kidney-Yin deficiency with Empty-Heat

The auricular inspection proposed by Chinese acupuncturists after 1958 goes beyond a simple somatotopic diagnosis as conceived in Western countries: it reflects the concept of the human body according to the rules of TCM. The body is a united totality of contradictions. Every single part of it is closely physiologically interconnected. After the onset of disease, a local ailment reflects itself on other parts as well as on the whole, while the transformation of the whole will certainly exert an influence locally. This is the reason why Chinese acupuncturists proposed a points selection for the ear according to the pien-cheng sih chih method, where pien-cheng means grasping the essence of a disease by distinguishing the subjective and objective symptoms, and sih chih means treating diseases according to the principles of TCM after analyzing and synthesizing a patient’s symptoms. In this way, for example, the heart and small intestine are correlated, and therefore a cardiovascular pathology will evoke a positive reaction on the ear’s area for the small intestine.⁴

It is interesting to recall the different stages in the Chinese experience: the first was the confirmation of the ear’s somatotopic representation of the different anatomical parts of the body through inspection, for example deformation or cartilaginous hypertrophy of the inferior crus of the anthelix in case of lumbar spondylosis or prolapsed intervertebral disk. Next came the proof that acupuncture treatment of dyschromia, telangiectasia, etc. within the somatotopic area related to a patient’s disease gave good results. Then came the pien-cheng sih chih method with the global consideration of the ear according to TCM. The last fascinating and at the same time complex stage was to obtain elements, through auricular inspection, for eventually revealing a suspected hidden tumor.

It is possible, in my opinion, that auricular inspection as proposed by Chinese acupuncturists has not been considered essential in the West because of the almost complete lack of photographic documentation. The historical textbook of the Nanjing military headquarters was the only one in the early 1970s that contained a few color plates related to diseases of the uterus, stomach and liver. A fourth plate showed desquamation of the lung area in a case of skin disease. Nanjing’s test, which has been translated into several languages, among them English ⁵ and Italian,⁶ reports type and location of the various skin alterations observed in the different diseases. Unfortunately the description of ‘positive reaction points,’ as they were called by the army doctors of the Nanjing garrison, does not follow any dermatological classification and we cannot understand, for example, what ‘congestive papules’ or ‘white small spots with reddish borders’ are. The authors, however, examined about 20 000 patients by simple inspection, reaching the conclusion that when certain internal organs or local areas of the human body suffer through illness, especially organic diseases, positive reactions will appear on the corresponding regions or specific areas of the majority of the patients. These pathological changes are symbolized by changes in skin color, deformation, desquamation and papules, etc.

The general instructions recommended by the authors for correct auricular inspection are as follows:

1. Careful attention must be paid to the patient’s skin which varies in summer and winter. The skin of an elderly person is not the same as that of a child. We should pay more attention to these distinctions.

2. Before observation, do not wipe, wash, lift or pull the auricle, to avoid causing discoloration of the skin or even elimination of matter which would greatly influence the accuracy of inspection. If a depressed area of the auricle is not clean, it may be wiped lightly in a given direction with a cotton swab.

3. When a positive reaction is found, the theory of zang-fu in TCM should be taken into consideration, and comprehensive analysis carried out by the pien-cheng method, to reach a diagnosis.

4. On the auricle of healthy persons there are often different manifestations such as pigmentations, white nodules, small pustules and scars from chilblains, etc. Most of these are ‘false appearances’. A method for distinguishing these is: first inspect, secondly press. If pressure does not cause pain this indicates that the manifestation pertains to a ‘false positive reaction’.

5. The light should be good, and natural light is preferable, though a flashlight may also be useful for appreciating the more internal parts of the auricle or its medial surface.

Points 2 and 5 are important for making a reliable inspection; as regards point 4, it is rare in our countries to find scars from chilblains. Tenderness at pressure of a skin alteration is, however, fundamental for diagnosis and may be used to treat symptoms. For example, acupuncture on a sensitive telangiectasia located within the representative area of a painful joint sometimes gives very quick and lasting relief.

Point 3 surely gives interesting indications for a general evaluation of the patient based on TCM syndromes. For example, desquamation of the lung area, as demonstrated also by Nogier, may direct the physician’s attention to possible skin disorders; a telangiectasia of the liver zone may orient his diagnostic intuition also toward depression and insomnia (see p. 97). Seborrhea of the cavum conchae instead may orient the acupuncturist’s diagnosis to metabolic disorders associated with food intolerance and diabetes if the pancreatic area is sensitive to pressure.

CLASSIFICATION OF SKIN ALTERATIONS OF THE OUTER EAR

Among the few Western authors who have given due importance to inspecting the outer ear and who have studied it systematically are Dr Nguyen in France and myself. Dr Nguyen has spoken about a ‘lésion cutanée ponctuelle’ (LCP) while I have spoken about ‘skin alterations’.

One of the major difficulties in ear inspection is how to classify the auricle’s skin alterations. Chinese authors limited the auricular reactions to four categories (change in color, deformation, papules and desquamation) whereas Nguyen proposed nine different categories distinguishing the following elements:⁷

• follicle (referring to sebaceous cyst)

I did not feel satisfied with this classification and here propose an alternative which in my opinion includes all of the auricle’s visible elementary skin lesions. In my research I was helped by a dermatologist, Antonia Pata, and together we set up a classification which includes six groups of alterations related to the vascularization, pigmentation, keratinization, cartilaginous, cutaneous and sebaceous gland structure of the auricle (Table 4.2).

Table 4.2 Classification of skin alterations (SAs) of the outer ear according to Pata and Romoli

Category	Type of SA	Pattern
SA related to vascularization	Paleness Hyperemia Telangiectasia Angioma	– reticular telangiectasia
		– punctiform telangiectasia
		– linear telangiectasia
		– spider angioma
		– punctiform angioma
SA related to pigmentation	Dyschromia Macula Nevus	– isolated spot
		– pigmented area
		– mixed melanin–hemosiderin area (grey, yellow, orange)
		– blue
		– melanocytic
SA related to keratinization	Dyskeratosis Dystrophy (skin is thin, lucent and fragile)	– furfuraceous scales
SA related to keratinization	Dyskeratosis Dystrophy (skin is thin, lucent and fragile)	– psoriasiform scales
SA related to cartilaginous structure	Hypertrophy (thickening) Hypotrophy (depression)
SA related to cutaneous structure	Depressed area Crease Incisure
SA related to sebaceous gland structure	Milium Sebaceous cyst Comedone

Using this classification I examined 711 patients of various ages (471 females, average age 46.9 years, range 12–92, SD 17.4; 240 males, average age 45.6 years, range 12–85, SD 18.4). I photographed both ears of every patient and reported on the Sectogram those skin alterations which I could detect with my naked eye. A database was created with the following data from every patient: age, sex, symptom prompting request for help, current or past important diseases, surgical operations, traumas, location and type of skin alterations. The main aim in assembling these data was to establish if ear inspection offers any elements of specificity which could be used in the process of auricular diagnosis. The total number of skin alterations was 8828 with an average of 12.4 skin alterations per patient, range 0–35, SD 4.7; the distribution on the right and left was almost equal; 52.7% on the right and 47.3% on the left auricle. The higher rate of skin alterations was found on the anthelix followed by the helix, the ear lobe and the cymba concha. A decreasing rate was found on the cavum concha and the medial surface of the ear; on the remaining parts (tragus, triangular fossa, intertragic notch) the rate did not reach 5% of the total (Table 4.3). The total number of skin alterations varies with the age of the patient and in both sexes there is a progressive increase passing from younger subjects to patients aged 70 or over (Fig. 4.2). The outer ear therefore acts as a mirror reflecting not only diseases of single organs but also the whole ageing process of a patient’s body. This process is not homogeneous on all auricular parts; indeed some of them, such as the ear lobe, anthelix, helix, tragus, antitragus and intertragic notch, show a significant correlation between age and the number of skin alterations (Table 4.4).

Table 4.3 Distribution of skin alterations (SAs) (summing those of the right and left ear) on the different parts of the auricle in 711 patients

Fig. 4.2 Regression line for age and number of skin alterations (SAs) in 711 consecutive patients.

Table 4.4 Correlation in 711 patients between age and the number of skin alterations on the auricle as a whole and on its different parts

Another parameter which varies with age and accompanies the increasing number of skin alterations is the number of hospitalizations and, to a lesser extent, the number of surgical operations, whereas the number of traumas remains constant throughout the decades examined (Fig. 4.3). The skin alterations are not evenly distributed through the six different categories: vascular skin alterations (particularly telangiectasia and hyperemia) correspond to 42.6% of the total followed by pigmented skin alterations (mainly nevi and maculae) corresponding to 26.2%; skin alterations of skin structure (creases and incisures) correspond to 15%. The remaining three groups follow with percentages below 5–10% (Fig. 4.4). The six categories of skin alteration have a different distribution on the 11 areas of the auricle. Telangiectasia are mostly seen on the anthelix, nevi prevalently on the helix followed by the ear lobe. Maculae have a uniform distribution on the anthelix, helix and lobe. The skin alterations of sebaceous gland structure (particularly comedones) were found mainly on the cymba conchae followed by the cavum conchae. Also depressions and dyskeratosis were found mostly on the cavum conchae. Also interesting is the comparison between the different percentage distribution throughout the six categories in the extremes of the age groups: younger people tended to have pigmented skin alterations (especially nevi) followed by vascular and sebaceous gland skin alterations (comedones), whereas in the oldest group of patients vascular skin alterations ranked first, followed by creases, incisures and pigmented skin alterations (especially maculae) (Fig. 4.5). The scantiness of skin alterations on the medial surface compared to those on the lateral surface is remarkable and only 902 (10.2% of the total) were found there. It is possible that this percentage could be higher if inspection of the medial surface were easier, if we consider that pain pressure test (PPT) tender points of this area in 325 patients were 14.4% and those with lower electrical resistance 19% of the total.

Fig. 4.3 Average number of surgical operations, traumas and hospitalizations in 711 patients according to four age groups (<30, 30–49, 50–69, ≥70 years).

Fig. 4.4 Percentage distribution of skin alterations (SAs) in each of the six categories in 711 patients.

Fig. 4.5 Percentage distribution of skin alterations (SAs) related to vascularization, pigmentation, cutaneous and sebaceous gland structure in the youngest age group (≤19) and in the oldest (≥70 years).

CASE STUDY

As an example of auricular inspection and correct methodology in recording skin alterations, I here report the case of an elderly woman. Considering type of skin alterations and above all their location, I could confirm the presence of some past and current health problems. In this case the difference between the richness of skin alterations on the lateral surface and their scantiness on the medial surface is clearly outlined.

The patient was a 77-year-old woman, 162 cm tall and weighing 65 kg (who in the past had weighed up to 83 kg). She had undergone the following surgical operations: appendectomy at the age of 19, uterine retroversion at age 27, crural hernia at 45, uterine–bladder prolapse at 60. She had suffered from depression when she was young and after menopause. She reported having suffered from chronic migraine for at least 50 years and even after menopause. She still suffered occasionally from attacks, mainly on the right side. She had had hypertension for at least 30 years, controlled by drugs. Some members of her family (brother, sister and nephew) had hypertriglyceridemia. Her levels of triglycerides had often been above average, reaching a maximum of 600 mg.

Her cholesterol levels had always been normal and there was no evidence of diabetes. She had had chronic lumbago in the L4–L5 herniated disk for over 20 years with recurrent sciatic and knee pain on the right side. She had also been suffering with bilateral neck pain for several years. Moreover, she suffered from gastritis and chronic dyspepsia, due also to her prolonged intake of NSAIDs. She had become increasingly deaf in recent years.

Inspection of the lateral surface of the right ear showed a series of skin alterations which can be described as follows (Fig. 4.6):

• The upper part of the ear shows a hyperemic area of the helix (sector 21 of the Sectogram); one telangiectasia and one hyperemia on the scapha and two neighboring hyperemic areas at the bifurcation of the superior and inferior crura of the anthelix. A small incisure and a few small furrows are visible respectively on the edge of the inferior crus of the anthelix and on the upper portion of the helix. The location of these skin alterations is consistent with the patient’s chronic back pain and recurrent sciatic pain.

• In the central part of the ear an oval area of cartilaginous hypertrophy is visible adjoining the root of the helix and surrounded on the upper border by a linear telangiectasia. These skin alterations are consistent with the patient’s gastritis and chronic dyspepsia. Below the root of the helix two sebaceous cysts are visible, one of them approaching the lung area. The sebaceous gland skin alterations of the upper and lower concha may orient the acupuncturist to suspect a hyperlipidemia (see Plate XVD) which in this case is confirmed by the increased levels of triglycerides.

• In the lower part of the ear two pigmented spots on the antitragus are visible. These can be considered indicative of the patient’s long history of migraine. Several creases and incisures are visible on the ear lobe: the creases are more evident on the anterior part and are consistent with the patient’s hypertension, and generally speaking with her cardiovascular risk. The small crease and the furrows on the posterior part of the lobe are consistent with the patient’s chronic depression and perhaps with her loss of hearing which has worsened in recent years. In spite of profuse skin alterations of the lateral surface, the medial surface shows only a few incisures on the lobe border and a deepening of the anthelix groove, relative to the patient’s chronic neck and back pain.

Fig. 4.6 Type and location of skin alterations in a 77-year-old female patient.

METHODOLOGY OF INSPECTION

It is necessary to inspect both ears even if the patient reports symptoms on only one side. One must be prepared for either the right or the left ear to give information and that more often the distribution of skin alterations will be asymmetrical.

At a glance the ear can immediately offer a series of clues, especially in the elderly. Inspection in younger patients may yield fewer diagnostic elements but at the same time could lead to the discovery of tendencies as yet unknown.

Inspection generally begins at the upper part and proceeds downwards, otherwise attention can be shifted from the helix to the concha. Once the accessible parts of the ear have been inspected, the hidden parts may be lifted or bent in order to obtain further information.

As regards the possible association between particular types of skin alteration and specific disorders, caution is recommended since a particular part of the ear may carry a prevalent type of skin alteration independently of the symptom believed to be associated with it. This is the case with the concha, which is the only part of the ear with sebaceous glands. It is not surprising therefore to find a high rate of comedones in this area since, as is known, these are plugs of sebum in a dilated pilosebaceous orifice. This process which is normal in this area may have a particular meaning if it is widespread (see Plates XVIB1 and XVIB2), or if limited zones of the concha show comedones of larger dimensions (see Plate XVA).

The histological structure of this skin is possibly also associated with a higher frequency of furfuraceous scales (dandruff) in this area, which again may be a clue to a specific syndrome in the patient (see Plate XVIA).

There are, however, differences in the distribution of skin alterations which do not depend on different histological patterns of the skin or a different nervous supply. In these cases other factors may be involved such as the representation on each auricular portion of specific anatomical structures of the body. For example it is very interesting to see how variable the ratio is between the vascular and pigmentary skin alterations on the different parts of the ear which have the same innervation: the ratio is 3.6 for the anthelix; 1.4 for the medial surface; 1.1 for the antitragus; 0.7 for the helix; 0.5 for the ear lobe. These differences make sense if we look at the topography of skin alterations: the skeletal apparatus with its muscles is represented on the anthelix and the medial surface of the ear. Therefore if hyperemia or telangiectasia are found on these parts it is reasonable to suspect a chronic or recurrent disorder of the locomotor system (see Plates IIA and IVA and IVD).

If, however, macules or nevi are found on the ear lobe or the helix, they may indicate some developmental defect of the spine and the cranial bones, or a tendency to mental disorders such as depression (see Plates XA, B, C, XIC and XIID).

Moreover, if we consider skin alterations related to cutaneous structure, such as depressed areas, creases and incisures, and their relative percentage of distribution on the different parts of the ear we find 6.5% and 7.6% on the anthelix and the medial surface of the ear, 11% on the helix and 26.7% and 39% respectively on the antitragus and the ear lobe. In my opinion incisures or creases of the antitragus or the ear lobe may be associated with symptoms related to a loss of function or to aging of the central nervous system (Plates XIIB and XIIIA, B, D).

As regards the topography of skin alterations, a reliable diagnostic clue becomes available if the area in which the skin alteration is located overlaps with the accepted representation of the corresponding anatomical part. In some cases, unfortunately, the expected correspondence is not found and incomplete overlapping of these areas may be misleading. This is the case, for example, of neighboring structures such as those pertaining to the lower and upper limbs. In the case of Plate IIIA, the telangiectasia appeared to overlap with the Chinese representation of the knee, but instead the patient had had a carpal syndrome for several months. We should by no means feel disappointed, but try with our medical knowledge to verify diagnosis through clinical judgment and the help of diagnostic instruments, imaging techniques and laboratory tests available in our profession.

One of the issues in inspection is to make an appropriate analysis of the various skin alterations observed in order to find the combination closest to diagnosing the current health problems of the patient. For example, to take notice of a diagonal ear lobe crease in a patient already under treatment with antihypertensive drugs may be less important than finding signs of an unexpressed depressive disorder. Since knowledge on the areas of the ear of possible use in the treatment of mental disorders is incomplete, I will present my considerations on this topic, which I consider to be very important, in a specific section later in this chapter.

DOES INSPECTION HAVE THE SAME VALUE IN ALL SECTORS OF THE OUTER EAR?

For all the following observations and analyses I have restricted the number of patients to the 357 that I had examined over the preceding 3 years.

If we consider the mean number of skin alterations on the right and left ear we obtain respectively 7.5 and 6.7. We would therefore expect a uniform distribution among the different sectors but this is not always the case. If we make a spatial cluster analysis ^8,⁹ of the total number of skin alterations on the right and left ears, regardless of sex, we may observe that there are some specific sectors with a significantly higher concentration. Figure 4.7 shows a distribution of skin alterations on the right ear which is quite uniform throughout from sector 3 to sector 19; on the left ear, there are two main groups of sectors on the upper and lower part of the auricle with a significantly greater cluster of skin alterations compared to the mean of the remaining sectors (Table 4.5A). It is possible that the reduced concentration of skin alterations on the remaining parts of the upper and lower conchae may be related to the more difficult visual access to these areas. Another possibility is that uneven or asymmetrical distribution of skin alterations in some sectors may be due to chance. This phenomenon in my opinion is worth particular consideration because it seemingly happens also if we apply the pain pressure test (PPT) (see Fig. 5.5) and electrical skin resistance test (ESRT) (see Fig. 7.1) in diagnostic procedures.

Fig. 4.7 Distribution of the total amount of skin alterations (SAs) on the right and left ear of 711 patients. The sectors with a significantly higher concentration of SAs at cluster analysis are colored.

Table 4.5A Sectors in which the number of skin alterations in 357 patients was significantly higher than the average of points per sector according to the Getis-Ord local statistic Gi ^8,⁹

The application of Nogier’s alignment principle to the inspection of the ear may furthermore add some elements to the issue of asymmetrical distribution of skin alterations. I have always been intrigued by aligned skin alterations because my clinical impression is that they can have a particular value for diagnosis and therapy to the pertaining sector, no matter to which category they belong. It should be pointed out here that the number of skin alterations which are aligned in two or more units is not negligible as it represents 38.5% of the total.

If we go back to the issue of asymmetrical distribution of skin alterations, we can see that the concentration of alignments on both auricles is not random but favors certain sectors above others. Cluster analysis indicates that sectors 9 and 16–19 on the right ear and 8–10 and 15–19 on the left ear have a significantly higher number of alignments than the average in the other sectors (Fig. 4.8; Table 4.5B).

Fig. 4.8 Distribution of skin alterations (SAs) which are aligned in two or more units on the right and left ear of 357 patients. The sectors with a significantly higher concentration of aligned SAs at cluster analysis are colored.

Table 4.5B Sectors in which the number of alignments of two or more skin alterations was significantly higher in 357 patients than the average of alignments per sector, according to the Getis-Ord local statistic Gi ^8,⁹

The majority of alignments consisted of two skin alterations (82.9%) and the minority of three (16.6%). Moreover the categories often seen in the alignment phenomenon are in decreasing order: two vascular skin alterations (see Plate IIA); one vascular and one pigmented (see Plate IXD); one vascular and one related to cartilaginous structure.

If we consider the auricular parts on which the skin alterations are more often aligned we find the same part in 23.6%, anthelix with helix or with medial surface in 21.3%, followed by lower concha with ear lobe or antitragus in 14.5%. The second group of combinations appears to be related to the frequent occurrence of musculoskeletal problems in the aging population; the latter, however, seems to be associated with the presence of psychosomatic and metabolic disorders so common in contemporary patients.

THE INSPECTION OF THE OUTER EAR IN THE LITERATURE

Before further describing some auricular signs and their possible association with patients’ symptoms it is necessary to recall what has been reported on this topic.

The following signs have been the object of inspection and have been reported in the literature or presented at congresses:

1. the diagonal ear lobe crease as a sign of cardiovascular risk

2. the skin alterations of the ear lobe for identifying new areas for the diagnosis and treatment of headache

3. the skin alterations of the concha as a complementary diagnostic tool in suspecting lesions of the upper digestive system

4. the auricular nevi in suspecting skeletal abnormalities

5. the crus cymbae in suspecting renal anomalies

6. last but not least, the possibility reported by Chinese authors that inspection may be of help in indicating the presence of a hidden tumor.

1 THE DIAGONAL EAR LOBE CREASE OR FRANK’S SIGN

One of the most investigated auricular signs in the literature is undoubtedly the diagonal ear lobe crease (ELC). When Frank ¹⁰ in 1973, in a letter to the New England Journal of Medicine, described his ‘aural sign of coronary artery disease’ he cannot have imagined that he would trigger a long and unbroken series of researches all over the world. There are probably 40 or more reports and articles in the literature, written mainly by cardiologists, dealing with the following aspects of the question:

• Is ELC a reliable diagnostic sign of coronary heart disease (CHD)?

• Does it have a predictive value for cardiac events such as cardiac death, acute myocardial infarction or coronary bypass operation in high risk patients?

• Can ELC be associated with conventional risk factors such as hypertension, smoking, diabetes, cholesterol, triglycerides, obesity, etc.?

• Should ELC be considered a sign of aging of the cardiovascular system?

• Should ELC be considered an androgen-sensitive trait like baldness and ear-canal hair?

Several authors tried to answer these questions but none of them was curious enough to seek a correlation with the representation of the homunculus on the pinna. On the other hand only a few acupuncturists were making an effort to understand the strange topography of a sign which apparently seems totally unrelated to the representation of the cardiovascular system.

As regards the investigations carried out by cardiologists, Tables 4.6 and 4.7 report a (probably incomplete) list of articles published in the period between 1974 and 2007.¹¹^–⁴⁹ While waiting for a complete systematic review on this topic the following information can be summarized from the tables:

1. ELC manifests itself after the age of 40 but becomes more evident and frequent around the sixth and seventh decades of life, especially in males. There is a general consensus that those patients showing an ELC before 40 have a higher risk of cardiovascular disease. Also performing an age- and sex-matched comparison with non-ELC subjects, the crease seems to be significantly correlated with a higher prevalence of CHD and a higher score of coronary stenosis in patients undergoing angiography (Table 4.6). Even in post-mortem studies there is a strong correlation between ELC with both the cardiovascular cause of death and the degree of atherosclerosis in the coronary and cerebral arteries and in the aorta (Table 4.7).

2. ELC may manifest unilaterally or bilaterally. Bilateral ELC, especially deep and clear-cut creases, seem prospectively to be associated with a lower cardiac event-free survival.³⁶

3. There is often a lack of association between ELC and the conventionally accepted risk factors. This inconsistency, whenever confirmed by a systematic review, closely recalls the controversy in the literature about the real importance of these factors. Indeed, it is still suggested by different authors that 50% of patients with CHD lack any of the conventional risk factors. This implies that other non-traditional factors could play a significant role in the development of this disease. However, the factors which seemingly show a higher association with ELC are hypertension and obesity.

4. ELC can be considered an indicator of biological age as opposed to chronological age and could be used to identify subjects who are aging more quickly than the general population. Biopsy sections from ear lobes at the site of the crease ¹⁹ report a premature destruction of elastic fibers in the skin which is similarly correlated with coronary artery disease (Fig. 4.9A, B).

5. Some articles report a possible association between CHD, ELC, ear-canal hair and male-pattern baldness. This association is supposed to be due to the long-term exposure to androgens which may facilitate the development of atherosclerosis and CHD.

Table 4.6 Study groups: association of ear lobe crease (ELC) with acute myocardial infarction (AMI) and coronary heart disease (CHD); association of ELC with the conventional risk factors. A review of the literature 1974–2007

Table 4.7 Post-mortem studies on causes of death and severity of atherosclerosis (in coronary and in cerebral arteries, and in the aorta) in patients with ear lobe crease (ELC). A review of the literature 1976–2006

Fig. 4.9 (A) Biopsy section from ear lobe in the area of crease (A); the arrow indicates elastic-fiber tears (×100) (with permission). (B) Biopsy section from area of ear lobe crease (ELC) the arrow indicates pre-arteriolar wall thickening (×240) (with permission).

There are, however, some aspects which have not been considered sufficiently and which require a careful and reliable standardization of the crease. The first is that the ELC was rarely evaluated by independent observers; the second is that differences in interpretation of the crease itself may account for at least a part of the different results in comparing subjects with and without CHD. For example, it is rarely stated if the creases are observed with the patient in the upright or the supine position; the creases are more evident in the second position. What is perhaps more important is that not all the authors have reached a consensus that ELC has to be considered present if it appears to involve the full thickness of the skin, extending entirely across the ear lobe. Only in a few articles has the crease been measured in three different degrees, as in the post-mortem study ⁴⁷ shown in Figure 4.10.

Fig. 4.10 Ear lobe crease (ELC) grading in a post-mortem study: A, B and C show representative cases that scored respectively 0, 1, 2 points (with permission).

However, the question that remains open for us is how to explain the topography of the crease and its relationship to the cardiovascular system. Cardiologist Yoshiaki Omura,⁵⁰ who was involved early in the observation of ear lobe creases, tried to explain the relationship between the ear lobe and myocardial abnormalities by a common neural supply. The main part of the lobe being innervated by the great auricular nerve (C2–C3), he surmised that there could be an ‘unrecognized supply of small branches of nerves coming directly or indirectly from the heart’. He supported his hypothesis with the possible observation in cardiac patients of a radiating pain involving also the neck, chin and occipital area, covered indeed by the same supply, C2 and C3.

Johan Nguyen ⁵¹ instead supposed that the correlation between a sign corresponding to the representation of the face and the heart could be explained only with the theory of TCM. He quoted as an example a sentence from the classical textbook Su Wen, Chapter 9, ‘The Heart is the source of life and the place of transformation of mental energy. Its energy manifests itself on the face.’

As regards my own opinion on this subject, I am far from being convinced that there is an easy approach to the question. I think two different topographical aspects have to be considered; the first is that the starting point of ELC, just below the intertragic notch, is constant for all types of creases. The second is the variable angle of the diagonal crease crossing the ear lobe and therefore encompassing a different surface of the anterior part of the lobe. The end point of a clear-cut crease can in certain cases reach the lowest point of the lobe or even trespass this limit backwards (see Plate XIIC); in other less frequent cases a double ELC can be observed (see Plate XIIB).

Concerning the starting point of the crease, Nogier’s map does not report any point related to the cardiovascular system in this area but shows the representation of the pituitary gland on the anterior ridge of the intertragic notch; the Chinese standardization, on the other hand, reports a puzzling tooth area (LO1 ya) with the indication for hypotension, besides toothache and periodontitis. The indication for raising blood pressure was maintained from the ancient map of the China Academy of TCM and is actually coincident with this starting point of the crease (Fig. 4.11). The possibility that this auricular area is related to dysfunctions of the cardiovascular system may be supported by the fact that just nearby on the tragus there are further points related to the heart such as xinzangdian of the ancient map, located within the current area TG1, with the indications of atrial fibrillation and tachycardia. Further points for treating hypertension are currently located in the area TG2 and adrenal gland shenshangxian located at the free border of the tragus between TG1 and TG2. The association of the tragus and the intertragic notch to diastolic pressure in hypertensive patients can be found in Chapter 5 (Figs 5.42, 5.43). As regards the possible association between CHD, ELC and ear-canal hair, which is supposed to be due to the long-term exposure to androgens, it is interesting from the topographic point of view that hair does not cover just the canal but also neighboring areas such as the tragus, the antitragus and the intertragic notch. All these areas appear to be involved in the regulation of neuroendocrine functions (Fig. 4.12).