Abstract
Abstract
Background:
Auricular diagnosis has been used as a complementary approach that is simple, effective, and inexpensive for identifying chronic illnesses. This diagnostic method has prediagnostic value and is important for a secondary level of prevention, so that earlier treatment can be provided.
Objective:
This article describes how this diagnostic method was applied in cases with coronary heart disease (CHD) or lower urinary-tract symptoms (LUTS), which are common chronic illnesses among the adult population.
Materials and Methods:
Design: A case-control study approach was adopted, with the utilization of visual inspection, electrical skin-resistance measurement, and tenderness testing to investigate the auricular signals and their relationship with specific chronic illnesses. The practitioners who conducted the auricular diagnosis were blinded to the known medical conditions of the subjects. Setting and Subjects: Subjects from the CHD +ve (positive) group (n=50) were recruited from the cardiac unit of a regional hospital in Hong Kong; whereas the subjects in the CHD −ve (negative; controls) group (n=50) and participants in the LUTS study (LUTS +ve and LUTS −ve; n=113) were recruited from the local community. Subjects with known health conditions were matched in age and gender with control subjects.
Results:
In the CHD study, the presence of an ear lobe crease was significantly associated with CHD. The Heart zone of the CHD +ve cases had significantly higher conductivity and had significant tenderness in both ears, compared with the control group. Similarly, nearly all of the specific acupoints in the participants in the LUTS +ve group indicated significantly higher conductivity and a tenderness sensation in the auricular areas associated with the kidneys and urinary tract than those in the LUTS −ve group. The predictive value of auricular signals for CHD/LUTS—which were detected by visual inspection, electrical skin-resistance measurement, and tenderness testing—was observed in a Chinese population.
Conclusions:
A systematic and scientific approach for the diagnostic accuracy of auricular signals involves using visual inspection, electrical skin-resistance measurement, and tenderness testing to investigate these signals and their relationship with specific chronic illnesses.
Introduction
T
Frank 3 first reported the association between the presence of an earlobe crease (ELC) and coronary heart disease (CHD). He identified diagonal creases on the earlobes that run either unilaterally or bilaterally from the lower probe of the external auditory meatus diagonally backward to the edge of the lobe. 4 Given that CHD is a common medical problem worldwide, early diagnosis of CHD via a noninvasive and effective approach is of great interest.
The prevalence of lower urinary-tract symptoms (LUTS) is common among elderly men. LUTS is a recent term for what was historically known as prostatism—a symptom resulting from the compression or obstruction of the urethra and irritating voiding disturbances, of which the principal underlying cause is benign prostatic hyperplasia (BPH) of the prostate gland. 5 Uroflowmetry, urine analysis, prostate-specific antigen, urinary cytology, ultrasound, imaging, cystoscopy, urodynamic pressure flow study, and measurement of the postvoided residual volume are existing Western diagnostic methods. 6 However, some of these diagnostic methods for LUTS are time-consuming, inefficient, inconvenient, and expensive. 7 LUTS can progress to chronic illnesses and significantly lower quality of life (QoL) in aging men.7,8 Therefore, a simple, effective, and inexpensive method for identifying LUTS status in patients could be very useful for early diagnosis and treatment.
The objectives of this study were as follows:
(1) To determine an ear diagnosis method for specific chronic illnesses via visual inspection, electrical skin-resistance measurement, and tenderness testing (2) To gain a better understanding of the predictive value of auricular signals among Chinese patients with CHD or LUTS.
Materials and Methods
Subjects and Settings
CHD study
This was a case–control study in which the subjects from the CHD +ve (positive for CHD) group were recruited from the cardiac unit of a regional hospital in Hong Kong. Half of the 50 subjects had experienced acute episodes (n=25), that is, the were newly diagnosed as having CHD (within 3 months), whereas the rest of the subjects had chronic CHD (n=25). All CHD +ve cases were compared with community subjects who were not diagnosed with CHD (CHD −ve [negative] group). These control subjects did not have any previous medical histories of CHD or any experience of having cardiac-related symptoms, including palpitations, chest pains, and/or dyspnea. The participants in the case and control groups were matched by age and gender.
Luts study
A total of 113 male participants were recruited through convenience sampling from five local senior centers located in different districts of Hong Kong. Cases were defined as those verified as having LUTS with an International Prostate Symptom Score (IPSS) total score of ≥8 (moderately symptomatic), or maximum urinary flow rate (Qmax)<15 mL/second, as measured by an uroflowmeter after screening, and/or a previous medical history of BPH.9,10 Controls were defined as subjects who did not have LUTS, using the criteria just mentioned. Only subjects ages ≥40 were included in the study.
Ethical Considerations
Ethical approval from the hospital and the universities involved was sought. Written informed consent was obtained from every eligible person who agreed to participate. The purpose and procedures of the study were explained verbally and in writing to the participants. Participation in these studies was on a voluntary basis, and all participants were assured that they have the right to refuse or withdraw from the study at any time. Personal information and data remained confidential and anonymous.
Methods of Ear Diagnosis
Ear diagnosis was conducted using three approaches: (1) visual inspection; (2) electrical detection; and (3) palpation for tenderness. The auricular diagnosis observer was blinded to the health condition grouping of the participants. Special auricular signals that were associated with coronary risks or LUTS were observed and recorded on both ears. The procedures used to assess the auricles are described in the following sections.
Visual inspection
In the CHD study, discoloration, appearance of edema ripples in the Heart region after pressing, presence of ear hair, and ELC were observed in both auricles. ELC was graded according to the system modified from Patel et al. 11 : grade 0=no crease at all; grade 1=any crease>0 but ≤50%; grade 2=> 50% but<100% across the lobe; grade 3=a complete crease across the lobe that is superficial but not deep; and grade 4=deep and prominent crease across the entire lobe. In the LUTS study, auricular signals, such as discoloration and presence of nodular scleroma, were observed in both auricles on seven specific auricular points, including the Angle of Superior Concha, Middle Superior Concha, Internal Genitals, Urinary Bladder, Ureter, Kidney, and Urethra.
Electrical skin-resistance measurement
An individual threshold was set for each subject before ear acupoint assessment. The threshold was obtained by placing an acupoint detector on the Shenmen point and increasing the detection sensitivity until the sound, lights, or visual meter on the equipment indicated high electrical conductance. The sensitivity was then slightly reduced until the Shenmen point was only barely detected.2,12 An electrical acupoint detector (Pointer Plus™) was used to measure the auricular electrical resistance in the specific acupoints under study.
Tenderness testing
A pressure algometer (force gauge) with a unit range of 0–500 g was used to apply force in the testing regions using the Shenmen point as a reference. The observed value (g) was recorded each time the subject began to feel pain when the pointer of the instrument was applied on the acupoints during testing.
Results
CHD Study
Among the 100 recruited participants, 50 were from a regional hospital in Hong Kong (25 acute cases and 25 chronic cases) and 50 were from the community (CHD −ve as controls). The mean age of the participants was 65.32 years (standard deviation [SD]=14.12), with 54 males and 46 females. The auricular signals found are described in the following sections.
Visual inspection
The presence of ELC, which is the primary auricular signal for CHD prediction in this study, was significantly associated with CHD. More participants in the CHD +ve group showed the presence of ELC in the auricular regions associated with coronary organs, compared with those ear acupoints in the CHD −ve group (p<0.05). More participants in the CHD +ve group also had ear hair growth than those in the CHD −ve group, especially in the right ear (p<0.01). Stratified analyses indicated that chronic cases had significant hair growth on the right ear.
Among these CHD +ve cases, the most commonly involved artery with blockage was the left anterior descending (75%), followed by the right coronary artery (RCA; 55.3%), left circumflex (44.7%), posterior descending artery (16.2%), and posterior lateral branch (2.6%). The degree of RCA stenosis was significantly associated with the presence of ELC on either the right (p<0.001) or left ear (p<0.05). The number of major epicardial arteries involved was also associated with the presence of ELC (p<0.01) and edema around the Heart zone (p<0.05) in the right ear.
Electrical skin-resistance measurement
The Heart zone of the CHD +ve cases had significantly higher conductivity in both ears (i.e., less electrical skin resistance), compared with the control group (p<0.01). Stratified analyses indicated a significant change in the conductivity of the Heart” zone in chronic CHD +ve cases (p<0.01) but not in acute cases.
Tenderness testing
The participants in the CHD +ve group experienced significant tenderness in the Heart region in both ears (p<0.001) compared with those in the CHD −ve group. A significant relationship was noted between the average tenderness (%) in both ears (r=0.707, p<0.001) in cases with either acute (p<0.01) or chronic conditions (p<0.01).
LUTS Study
The mean age of the participants (n=113) was 74.36 years (SD=7.59). All participants were men. The mean IPSS scores of participants for the LUTS +ve and LUTS −ve groups were 14.64 (SD=5.93) and 3.09 (S.D.=2.84), respectively. Statistically significant differences were observed in each domain of the IPSS scale between groups in terms of the symptoms related to LUTS, including incomplete emptying (p<0.001), frequency (p<0.001), intermittency (p<0.001), urgency (p<0.001), weak stream (p<0.001), straining (p<0.001), and nocturia (p<0.001). The mean Qmax of participants for the LUTS +ve and LUTS −ve groups were 8.40 mL/second (SD=3.45) and 17.94 mL/second (S D=14.77), respectively. The auricular signals found are described in the following sections.
Visual inspection
In general, no significant differences in discoloration and presence of nodular scleroma in specific acupoints were found between the LUTS +ve and the LUTS − ve groups.
Electrical skin-resistance measurement
Nearly all of the specific acupoints in the participants in the LUTS +ve group (except the Urethra in both ears and the Ureter in the left ear) had significantly higher conductivity than those ear points in the LUTS −ve group. In the right ear of the participants, the electrical conductivity of the Angle of Superior Concha had a maximum sensitivity of 0.74 and a negative predictive value (NPV) of 0.58. The Kidney” had a maximum specificity of 0.68 and a positive predictive value (PPV) value of 0.76 among the selected acupoints that were tested. The Angle of Superior Concha in the left ear indicated a maximum sensitivity of 0.70, a PPV of 0.73, and an NPV of 0.55, compared with the other acupoints.
Tenderness testing
The participants in the LUTS +ve group experienced significant tenderness in almost all of the specific acupoints (except the Angle of Superior Concha and the Urinary Bladder in the right ears), compared with the same auricular regions in the participants of the LUTS −ve group. The Angle of Superior Concha had considerable sensitivity (0.49 versus 0.58), specificity (0.73 versus 0.62), PPV (0.74 versus 0.70), and NPV (0.48 versus 0.48) in the right versus the left ear during tenderness testing.
Discussion
This study adopted a systematic and scientific approach using visual inspection, electrical skin-resistance measurement, and tenderness testing to investigate auricular signals and their relationships with two chronic problems, namely, CHD and LUTS.
The results of the CHD study suggested that the presence of ELC, high electrical conductivity, and tenderness of the Heart region is associated with the presence of CHD. These findings could advance our knowledge and lead to an integrated approach for combining Chinese and Western models of care for diagnosing patients with underlying CHD.
Several researchers have speculated that creasing is associated with earlobe shape, variation in age of creasing onset according to race, and variation in the frequencies of occurrence of different earlobe shapes by race. 13 The subjects included in the current study were Asian Chinese, which limits the generalizability of the findings to other populations. Given possible cultural differences in ELC presentation, further studies on earlobe creases should consider the effects of age, race, and earlobe shape on ELC prevalence.
Although retrospectively examining the auricles from the time of birth of these subjects was impossible, the current authors speculate that the crease is not present at birth and develops later in life. However, whether or not the crease is a genetic predisposition that takes years to appear or a result of localized vascular disease and skin atrophy remains to be determined. 14 More participants in the CHD +ve group had hair growth in their ears than those in the CHD −ve group. This finding agrees well with the observations reported by Verma et al., who showed that excessive hair growth in the meatus externa has a correlation with CHD. 15
The electrical resistance in the corresponding auricular points decreases when a disease or disorder is present in the body, and areas with lower electrical resistance than that of the standard measurements are considered either positively or highly conductive electrical resistance points. 12 In the CHD study, a significant change was observed in the conductivity of the Heart zone in chronic CHD +ve cases but not in acute cases. The change in electrical conductivity of acupoints may need some time to develop and is present when the disease progresses.
The degree of acupoint tenderness is usually associated with the severity of the condition; the more sensitive the point, the more severe the disorder will be.2,16 Among the three examination methods adopted for the CHD study, tenderness testing of the Heart zone had the highest sensitivity (92.0%) and the highest positive value (78.6%) for prediction of CHD status.
In the LUTS study, visual inspection of the acupoints that were tested might not have been a reliable measure for detecting LUTS status. However, nearly all of the specific acupoints on the participants in the LUTS +ve group had significantly higher conductivity than those same acupoints in the LUTS −ve group. In addition, the participants in the LUTS +ve group experienced significantly higher tenderness in almost all of the specific acupoints, compared with those in the LUTS −ve group in both ears. While LUTS does not pose a threat for serious illnesses or degradation of the physical integrity of elderly men, the effect of LUTS on increased risk of falls and fall-related injuries, increased risk of emotional and psychologic problems, and diminished QoL of patients with LUTS affected should not be undermined.
Implications of the Findings
The results of this study can improve our knowledge of the association between specific auricular reflective signs and certain chronic illnesses. Auricular diagnosis has a prediagnostic value and is important for a secondary level of prevention. Prognosis may be improved by early preventive measures, if chronic conditions can be identified at earlier stages.
The examination of the external ear is a diagnostic procedure that may be easily integrated into routine clinical examination of a patient in to increase the predictive accuracy of detection of underlying problems for earlier introduction of preventive measures before a disease advances. Given that the external ear can be a valuable tool for indicating constitutional predispositions, auricular diagnosis, if found to be effective in additional studies, can be used as a complementary diagnostic approach. This method is simple, effective, and inexpensive for identifying patients with medical problems.
Limitations of the Study
This study suggests an association between ELC and CHD, but the mechanisms leading to the concurrent development of ELC and CHD and the time of onset remain unknown. A future prospective cohort study could be conducted to follow-up newly diagnosed medical illnesses and identify changes in the auricular signals that may have appeared during disease progression. The investigations described in this article were conducted on relatively small samples. Therefore, further investigations must be performed with larger samples to validate using auricular signs as predictors to help CHD/LUTS diagnosis. The auricular signals may be governed by ethnic differences; more investigations are required before these results can be extrapolated to other ethnic groups besides the one in the current study.
Conclusions
The predictive value of auricular signals on CHD/LUTS—which were detected by visual inspection, electrical skin-resistance measurement, and tenderness testing—was observed in a Chinese population. Auricular diagnostic findings obtained with blinded assessment of participants can improve our knowledge and lead to an integrative approach that combines Chinese and Western models of care to diagnose patients with these underlying conditions. Further studies, with larger samples, should be conducted to ascertain the diagnostic value of auricular signals for detecting chronic conditions.
Footnotes
Acknowledgments
This CHD project was supported by the Cardiovascular Diseases Management and Prevention Group, The Nethersole School of Nursing, The Chinese University of Hong Kong. The LUTS project was supported by the Division of Transitional, supportive and palliative care group, School of Nursing, The Hong Kong Polytechnic University. The authors also extend their appreciation to the volunteers for their participation and cooperation in these studies.
Disclosure Statement
No competing financial interests exist.