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Background:
Systematic Review

Petrified Ear in Adrenal Insufficiency: Systematic Literature Review

by
Elisa Jörg
1,
Gregorio P. Milani
2,3,
Sebastiano A. G. Lava
4,
Mario G. Bianchetti
1,5,*,
Gabriel Bronz
6,
Pietro B. Faré
6 and
Maristella Santi
7,8
1
Family Medicine Institute, Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland
2
Pediatric Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
3
Department of Clinical Sciences and Community Health, Università Degli Studi di Milano, 20122 Milan, Italy
4
Pediatric Cardiology Unit, Department of Pediatrics, Centre Hospitalier Universitaire Vaudois and University of Lausanne, 1005 Lausanne, Switzerland
5
Pediatric Institute of Southern Switzerland, Ente Ospedaliero Cantonale, 6500 Bellinzona, Switzerland
6
Department of Internal Medicine, Regional Hospital of Locarno, Ente Ospedaliero Cantonale, 6600 Locarno, Switzerland
7
Department of Pediatrics, Fribourg Hospital HFR, 1708 Fribourg, Switzerland
8
Faculty of Science and Medicine, University of Fribourg, 1700 Fribourg, Switzerland
*
Author to whom correspondence should be addressed.
J. Clin. Med. 2025, 14(19), 6870; https://doi.org/10.3390/jcm14196870 (registering DOI)
Submission received: 6 August 2025 / Revised: 10 September 2025 / Accepted: 17 September 2025 / Published: 28 September 2025
(This article belongs to the Section Endocrinology & Metabolism)
Browse Figure
Versions Notes

Abstract

Background: Adrenal insufficiency has been recognized as a condition linked to petrified ear. To further explore this issue, we conducted a review of the literature. Methods: The study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines after pre-registration. Excerpta Medica, the National Library of Medicine, and Web of Science databases without language restrictions were used. Inclusion criteria comprised adrenal insufficiency and the presence of petrified ear. Data extraction included demographics, clinical and laboratory features, and outcome. Results: Thirty-six reports were identified, encompassing 40 cases: 38 males and 2 females, aged between 22 and 79 years. All cases exhibited bilateral petrified ears, with 18 cases of primary adrenal insufficiency and 20 cases of central insufficiency. The type of adrenal insufficiency was not specified in two cases. Sixteen patients had concurrent endocrine disorders. In primary adrenal insufficiency, petrified ear was typically (N = 13; 72%) detected two or more years after the endocrine diagnosis. In central adrenal insufficiency, auricular calcification was identified either prior to or at the time (N = 17; 85%) of the endocrine diagnosis. Petrified ear was never associated with hearing impairment and never improved with therapy. Conclusions: In adrenal insufficiency, petrified ear is always bilateral, affects adult males, occurs in both primary and central forms of the disease and does not improve on therapy. In primary insufficiency, this feature is mostly observed two years after the endocrine diagnosis, whereas in central cases, it is identified before or concurrently with the endocrine diagnosis.

1. Introduction

In 1866, the Czech anatomist Vincenz Bochdalek (1801–1883) reported that the auricle may occasionally present as rigid, hard, thick, and with a rock-like consistency [1]. This typically asymptomatic yet remarkable and uncommon clinical finding is referred to as petrified ear, petrified auricle, or stony ear, and may result from calcification, ossification, or both [2].
Repeated physical trauma to the auricle, prolonged exposure to cold (with or without frostbite), chronic infections, and endocrine diseases such as hypothyroidism and acromegaly have been proposed as potential contributing factors [3,4,5]. Of particular note, adrenal insufficiency has been recognized since at least 1954 as a condition associated with petrified ear [6], a feature that has since been reported exclusively in isolated case reports, thereby highlighting both its rarity and diagnostic significance.
Textbooks and authoritative reviews generally describe hyperpigmentation affecting sun-exposed areas, palmar creases, flexural surfaces, friction sites, recent scars, genital skin, and mucous membranes as hallmark dermatological and mucosal features of primary adrenal insufficiency [7]. By contrast, the occurrence of petrified ear in the setting of adrenal insufficiency is either not mentioned at all or only marginally addressed in these sources [7,8,9], despite its potential clinical relevance. Case reports undoubtedly offer valuable insights into rare and unusual manifestations, yet it is only through their systematic aggregation and critical evaluation that consistent patterns can be recognized, clinical characteristics more clearly delineated, and possible pathophysiological mechanisms revealed. Motivated by these considerations, and further stimulated by our direct encounter with a male patient simultaneously presenting adrenal insufficiency and petrified ear, we undertook a systematic review of the literature. This effort aimed not only to collect clinical observations but also to provide a structured framework for understanding this uncommon, intriguing association.

2. Materials and Methods

2.1. Literature Search Strategy

This study was pre-registered with the International Prospective Register of Systematic Reviews (PROSPERO: CRD42025633721) and was conducted in accordance with the guidelines outlined in the 2020 edition of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Literature searches were performed in Excerpta Medica, the National Library of Medicine, and Web of Science databases, for articles or letters published since 1954 without language restrictions. Search terms included (“ear” OR “calcification of the ear” OR “auricular cartilage calcification” OR “petrified ears”) AND (“adrenal insufficiency” OR “corticoadrenal insufficiency” OR “Addison’s disease”). Additional references were identified through Google Scholar and bibliographies of retrieved records. The search was conducted in January 2025 and repeated on 31 August 2025. After a preliminary screening based on titles and abstracts, the full texts of the selected studies were reviewed for eligibility.

2.2. Selection Criteria—Data Extraction

Original reports documenting otherwise unexplained cases of petrified ear in patients of all ages diagnosed with primary or central adrenal insufficiency were considered. Cases published solely as abstracts were disregarded. The following five data sets were extracted for each individual with petrified ear linked to adrenal insufficiency using a structured piloted form: (1) demographics and temporal relationship between diagnosis of adrenal insufficiency and recognition of petrified ear (clinical sign detected before endocrine diagnosis by ≥2 years, clinical sign and endocrine diagnosis detected concurrently, clinical sign detected ≥2 years after endocrine diagnosis), (2) laboratory data supporting the classification of adrenal insufficiency as primary or central, (3) the presence of other concomitant endocrine disorders (such as diabetes mellitus, growth hormone deficiency, hyperprolactinemia, hypogonadism, or hypothyroidism), (4) blood levels of “phosphocalcemic factors” such as calcium, inorganic phosphate, parathyroid hormone, and vitamin D [10], (5) investigations, in addition to clinical examination, documenting the petrified ear, its clinical course, and the presence of hearing impairment.

2.3. Reporting Thoroughness—Statistics

For each individual case, the thoroughness of reporting for the five specified data sets was assessed on a scale of 0, 1, or 2. Based on the total score, the overall thoroughness of reporting for each case was categorized as excellent (9 or 10), good (7 or 8), or satisfactory (5 to 7), according to our standard procedure [11,12].
Two authors independently and in duplicate conducted the literature search, selected reports for inclusion, extracted the data using a structured, pilot-tested paper form, and assessed the thoroughness of each reported case. Any discrepancies were resolved through discussion, with input from a senior author when necessary. One author then entered the data into a spreadsheet, while another cross-checked their accuracy.
Pairwise deletion was applied to address missing data [13]. Categorical variables are presented as absolute counts and, where appropriate, also expressed as percentages. Percentages were rounded to the nearest whole number when the value was equal to or greater than 10, whereas for values below 10, they were rounded to one decimal place. Binary data were analyzed using Fisher’s exact test, while ordered data were evaluated with the Wilcoxon–Mann–Whitney rank-sum test [14]. Continuous variables are presented as medians with interquartile ranges (≥5 cases) or as individual values (<5 cases) and were assessed using the Kruskal–Wallis test by ranks [14]. A two-sided p-value threshold of <0.05 was used to determine statistical significance. GraphPad Prism version 10.4.1 (GraphPad Software, San Diego, CA, USA) was used for all analyses.

3. Results

3.1. Search Results

The study flowchart is shown in Figure 1.
For the final analysis, we reviewed 36 reports published since 1955 that documented auricular calcifications linked to adrenal insufficiency [15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50]. The articles were written in English (N = 28), German (N = 4), Spanish (N = 3), and French (N = 1). They came from the following continents: 17 from Europe (Germany, N = 3; Spain, N = 3; Switzerland, N = 3; Italy, N = 2; France, N = 1; Greece, N = 1; The Netherlands, N = 1; Portugal, N = 1; Romania, N = 1; United Kingdom, N = 1), 11 from Asia (Israel, N = 4; Japan, N = 3; India, N = 2; Taiwan, N = 1; Türkiye, N = 1), and 8 from America (United States, N = 6; Canada, N = 1, Chile, N = 1). The 36 selected articles documented 40 individuals with petrified ear linked to adrenal insufficiency. Reporting thoroughness was assessed as excellent, good, and satisfactory in 17 (43%), 17 (43%), and 6 (15%) cases, respectively.

3.2. Findings

The diagnosis of petrified was established clinically in all 40 cases. Imaging studies confirmed the diagnosis in 35 cases, while a biopsy provided additional confirmation in 7 cases.
The characteristics of the 40 patients appear in Table 1.
Petrified ear was always bilateral and was recognized exclusively in adults, with 95% of cases being male. Primary and central adrenal insufficiency were represented in a similar manner (this classification was not possible in two cases).
Adrenal insufficiency was associated with at least one more endocrine condition in 40% of cases. The overall prevalence (p = 0.0070) of associated endocrine conditions, especially hypogonadism (p = 0.0366), was significantly higher in central than in primary cases. The prevalence of hypothyroidism, diabetes mellitus, growth hormone deficiency, and hyperprolactinemia was similar in cases of primary and central adrenal insufficiency.
In primary adrenal insufficiency, petrified was typically (72%) detected two or more years after the endocrine diagnosis. In contrast, in the majority (85%) of central adrenal insufficiency cases, petrified ear was identified either prior to or at the time of the endocrine diagnosis. This difference was statistically significant (p = 0.0381). Hypercalcemia, hyperphosphatemia, elevated parathyroid hormone or vitamin D levels were almost never described.
Finally, petrified ear was never associated with hearing impairment and did not improve with replacement therapy.

4. Discussion

This systematic review of the literature on petrified ear in adrenal insufficiency indicates that this clinical feature is always bilateral, almost uniquely affects adult males, occurs in both primary and central forms of the disease, is often associated with other endocrine diseases, and does not improve on therapy. In primary adrenal insufficiency, the feature is typically recognized two or more years after the endocrine diagnosis. In contrast, in cases with central adrenal insufficiency, the feature is generally identified either prior to or at the time of the endocrine diagnosis.
The mechanisms driving petrified ear in adrenal insufficiency are not well understood. However, it is mostly thought to be attributable to hypercalcemia, a recognized electrolyte disturbance in adrenal insufficiency [7,8,9,10]. Parathyroid hormone and 1,25-dihydroxyvitamin D are generally reduced in hypercalcemic individuals with adrenal insufficiency, indicating a suppressed parathyroid hormone–vitamin D axis [7,8,9,10]. In this context, hypercalcemia is currently thought to result from increased bone resorption that occurs independently of parathyroid hormone, and from fluid volume depletion [10,51,52]. In patients with petrified ear linked to adrenal insufficiency, hypercalcemia had virtually never been documented. However, it is plausible that petrified ear might be linked to prior episodes of hypercalcemia. This speculation is supported by the fact that chronic hypercalcemic disorders such as primary hyperparathyroidism and sarcoidosis are recognized triggers of petrified ear [51,52]. Excess adrenocorticotropic hormone is a well-recognized cause of tissue calcification [5,53]. However, this mechanism is unlikely to explain adrenal insufficiency-associated petrified ear, as the condition has been observed in both primary and central forms [7,8,9].
Petrified ear, whether associated with adrenal disorders or not, affects almost exclusively males [3,4,5]. Although the underlying mechanisms remain unknown, it is conceivable, though not demonstrated, that estrogens may play a protective role [54].
It is plausible that the pathological process underlying petrified ear may also involve the middle or inner ear, thereby leading to hearing impairment. However, in none of the cases of petrified ear included in our analysis was hearing impairment documented. It is nevertheless likely that this aspect has not always been investigated. We therefore recommend that this possibility be considered in patients with petrified ear.
While the hypothalamic–pituitary–adrenal axis is altered in both primary and central adrenal insufficiency, the renin-angiotensin II-aldosterone axis and the adrenal medullary function are affected only in the primary form [7,8,9]. Both types of adrenal insufficiency present with chronic, non-specific features like fatigue, weight loss, gastrointestinal discomfort, and joint or muscle pain, but water and electrolyte disturbances mainly occur in primary adrenal insufficiency. As a result, diagnosis is typically quicker in the primary form [7,8,9]. This may be why petrified ears are often detected at diagnosis in central adrenal insufficiency.
The prevalence of petrified ears in adrenal insufficiency is unknown, but likely very low considering that only 40 cases have been reported since 1955. According to a report published in 1954, the existence of petrified ear would have been observed in 6 out of 120 patients with adrenal insufficiency [6]. To the best of our knowledge, the prevalence of this sign among individuals with adrenal insufficiency has never been addressed in the literature since. Because adrenal insufficiency is nowadays diagnosed earlier than 70 years ago, we suppose that this feature might be even less common today.
Besides petrified ear, petrified auricle, and stony ear, the term auricular cartilage calcification is also used. We recommend avoiding “cartilage” and favoring auricular calcification, although all these terms inadequately capture the associated thickening of the auricle.
Rediscovering the value of bedside skills is crucial, as they remain central to timely and accurate diagnosis despite rapid technological progress. In medical practice, technology has advanced tremendously, often reducing the emphasis on skills like history taking and physical examination. Nevertheless, inadequacies of history taking or examination, often oversights, remain recognized contributors to medical errors [55,56]. Because the presentation of adrenal insufficiency is nonspecific, this diagnosis is often delayed [7,8,9]. The findings of this literature review indicate that petrified ear, along with hyperpigmentation, constitutes a simple and noteworthy clinical sign. On one hand, petrified ear should be sought whenever adrenal insufficiency is suspected; on the other hand, bilaterally petrified ears with no evident cause should prompt consideration of adrenal insufficiency.
Future research may first involve a structured survey among endocrinologists to better estimate how frequently petrified ear occurs and to what extent it is recognized in routine clinical practice. Another promising line of investigation would be to assess whether comparable processes of calcification and ossification are present in other anatomical sites, thereby shedding light on possible systemic mechanisms underlying this condition [6]. Finally, in vitro studies of cartilaginous tissue could provide important mechanistic insights by comparing cellular and structural changes under different hormonal environments, particularly in the presence or absence of cortisol and estrogens [54]. Considering that petrified ear almost exclusively affects males, such experiments would be especially relevant to clarify the role of sex hormones in the pathogenesis and potential protection afforded by estrogens [54].
This systematic review has both limitations and merits. The main limitations are the small sample size and incomplete reporting in some cases, which may reduce the generalizability of the results. Furthermore, diagnostic techniques used until the 1980s were often relatively rudimentary. An additional drawback is that the prevalence of this sign remains unknown. The merits include its pre-registration, a thorough case selection methodology, and the use of multiple languages. Additionally, the study highlights a rarely discussed feature of adrenal insufficiency, provides some new insights on the condition, and presents a review spanning seven decades.

5. Conclusions

This review identifies petrified ear as a rare feature of adrenal insufficiency, highlighting its earlier detection in central compared to primary forms. The finding that this clinical feature does not improve with therapy underscores its potential as a distinctive and lasting diagnostic marker. By firmly linking this uncommon sign to adrenal insufficiency, the study provides clinicians with a simple yet valuable clue that can meaningfully aid in diagnosis.

Author Contributions

Conceptualization: E.J., M.G.B. and M.S.; Literature search: G.P.M. and G.B.; Literature analysis: E.J., G.P.M. and M.S.; Supervision: S.A.G.L. and P.B.F.; Original draft of the manuscript: E.J., M.G.B. and M.S.; Review and editing of the manuscript: all authors. All authors have read and agreed to the published version of the manuscript.

Funding

The study was partially funded by the Italian Ministry of Health (Ricerca Corrente).

Institutional Review Board Statement

Not applicable for studies not involving humans.

Informed Consent Statement

Not applicable.

Data Availability Statement

Data sharing does not apply to this article, as no new data were generated during this study.

Conflicts of Interest

The authors declare no conflicts of interest.

References

  1. Bochdalek, V.A. Verknöcherung der Aurecula. Prag. Vierteljahrschr. 1866, 89, 33–46. [Google Scholar]
  2. Wassmund. Verknöcherung der Ohrmuschel und Röntgographie. Dtsch. Med. Wochenschr. 1899, 25, 439–440. [Google Scholar] [CrossRef]
  3. High, W.A.; Larson, M.J.; Hoang, M.P. Idiopathic bilateral auricular ossificans: A case report and review of the literature. Arch. Pathol. Lab. Med. 2004, 128, 1432–1434. [Google Scholar] [CrossRef] [PubMed]
  4. Karrs, J.X.; Bass, J.; Karrs, T. Inflexible ears. JAMA Dermatol. 2016, 152, 335–336. [Google Scholar] [CrossRef]
  5. Valea, A.; Nistor, C.; Ciobica, M.L.; Sima, O.C.; Carsote, M. Endocrine petrified ear: Associated endocrine conditions in auricular calcification/ossification (a sample-focused analysis). Diagnostics 2024, 14, 1303. [Google Scholar] [CrossRef] [PubMed]
  6. Jarvis, J.L.; Jenkins, D.; Sosman, M.C.; Thorn, G.W. Röntgenologic observations in Addison’s disease; a review of 120 cases. Radiology 1954, 62, 16–29. [Google Scholar] [CrossRef] [PubMed]
  7. Nieman, L.K.; Chanco Turner, M.L. Addison’s disease. Clin. Dermatol. 2006, 24, 276–280. [Google Scholar] [CrossRef]
  8. Hahner, S.; Ross, R.J.; Arlt, W.; Bancos, I.; Burger-Stritt, S.; Torpy, D.J.; Husebye, E.S.; Quinkler, M. Adrenal insufficiency. Nat. Rev. Dis. Primers 2021, 7, 19. [Google Scholar] [CrossRef]
  9. Kumar, R.; Wassif, W.S. Adrenal insufficiency. J. Clin. Pathol. 2022, 75, 435–442. [Google Scholar] [CrossRef]
  10. Montoli, A.; Colussi, G.; Minetti, L. Hypercalcaemia in Addison’s disease: Calciotropic hormone profile and bone histology. J. Intern. Med. 1992, 232, 535–540. [Google Scholar] [CrossRef]
  11. Kottanattu, L.; Lava, S.A.G.; Helbling, R.; Simonetti, G.D.; Bianchetti, M.G.; Milani, G.P. Pancreatitis and cholecystitis in primary acute symptomatic Epstein-Barr virus infection—Systematic review of the literature. J. Clin. Virol. 2016, 82, 51–55. [Google Scholar] [CrossRef]
  12. Betti, C.; Lavagno, C.; Bianchetti, M.G.; Kottanattu, L.; Lava, S.A.G.; Schera, F.; Lacalamita, M.C.; Milani, G.P. Transient secondary pseudo-hypoaldosteronism in infants with urinary tract infections: Systematic literature review. Eur. J. Pediatr. 2024, 183, 4205–4214. [Google Scholar] [CrossRef]
  13. Papageorgiou, G.; Grant, S.W.; Takkenberg, J.J.M.; Mokhles, M.M. Statistical primer: How to deal with missing data in scientific research? Interact. Cardiovasc. Thorac. Surg. 2018, 27, 153–158. [Google Scholar] [CrossRef] [PubMed]
  14. Gaddis, G.M.; Gaddis, M.L. Introduction to biostatistics: Part 5, Statistical inference techniques for hypothesis testing with nonparametric data. Ann. Emerg. Med. 1990, 19, 1054–1059, Erratum in Ann. Emerg. Med. 1991, 20, 573. [Google Scholar] [CrossRef]
  15. Anschütz, F.; Dontenwill, W. Über Verkalkung des Ohrknorpels bei der Addisonschen Erkrankung [Calcification of the ear cartilage in Addison’s disease]. Ärztl Wochensch. 1955, 10, 136–137. [Google Scholar] [PubMed]
  16. Novick, W.H. Calcification of auricular cartilage in Addison’s disease. Arch. Otolaryngol. 1960, 72, 448–449. [Google Scholar] [CrossRef]
  17. McKusick, V.A.; Goodman, R.M. Pinnal calcification: Observations in systemic diseases not associated with disordered calcium metabolism. JAMA 1962, 179, 230–232. [Google Scholar] [CrossRef]
  18. Randall, R.E., Jr.; Spong, F.W. Calcification of the auricular cartilage in a patient with hypopituitarism. N. Engl. J. Med. 1963, 269, 1135–1137. [Google Scholar] [CrossRef]
  19. Gordon, D.L. Calcification of auricular cartilage. Arch. Intern. Med. 1964, 113, 23–27. [Google Scholar] [CrossRef]
  20. Bedsole, A. Calcified auricular cartilages in Addison’s disease. South. Med. J. 1966, 59, 1268–1270. [Google Scholar] [CrossRef]
  21. Siebenmann, R.E. Die Ohrknorpelverknöcherung beim Morbus Addison [The ossification of the ear cartilage in Addison’s disease]. Schweiz. Med. Wochenschr. 1977, 107, 468–474. [Google Scholar]
  22. Chadwick, J.M.; Downham, T.F., 2nd. Auricular calcification. Int. J. Dermatol. 1978, 17, 799–801. [Google Scholar] [CrossRef]
  23. Zillessen, E.; Gless, K.H.; Baldauf, G. Verknöcherung der Ohrmuschel bei partieller Hypophyseninsuffizienz mit selektivem ACTH- und STH-Mangel [Ossification of the auricle in partial pituitary failure with selective ACTH and STH deficiency (author’s transl)]. Dtsch. Med. Wochenschr. 1978, 103, 698–701. [Google Scholar] [CrossRef]
  24. Barkan, A.; Glantz, I. Calcification of auricular cartilages in patients with hypopituitarism. J. Clin. Endocrinol. Metab. 1982, 55, 354–357. [Google Scholar] [CrossRef]
  25. Gómez Huelgas, R.; Obeso Fernández, G.; Lacambra Calve, C.; Pereda García, J.M. Calcificación de los cartílagos auriculares en dos pacientes con enfermedad de Addison [Calcification of auricular cartilages in two patients with Addison’s disease]. Rev. Clin. Esp. 1988, 182, 118. [Google Scholar]
  26. Cohen, A.M.; Talmi, Y.P.; Floru, S.; Bar Ziv, J.; Zohar, Y.; Djaldetti, M. Ossification of the auricle in Addison’s disease. J. Laryngol. Otol. 1989, 103, 885–886. [Google Scholar] [CrossRef]
  27. Talmi, Y.P.; Cohen, A.M.; Bar-Ziv, J.; Finkelstein, Y.; Floru, S.; Zohar, Y. Ossified auricle in Addison’s disease. Ann. Otol. Rhinol. Laryngol. 1990, 99 Pt 1, 499–500. [Google Scholar] [CrossRef] [PubMed]
  28. Cohen, A.M.; Talmi, Y.P.; Floru, S.; Tsigelman, R.; Kalmanovitz, M.; Zohar, Y.; Djaldetti, M. X-ray microanalysis of ossified auricles in Addison’s disease. Calcif. Tissue Int. 1991, 48, 88–92. [Google Scholar] [CrossRef]
  29. Calvo Catalá, J.; Hortelano Martínez, E.; González-Cruz Cervellera, M.I.; Climent Díaz, B.; Ortega Gonzålez, E.; Valero Prieto, I. Calcificación de los cartílagos auriculares en un paciente con insuficiencia suprarrenal: Aportación de un caso y revisión de la literatura [Calcification of auricular cartilages in a patient with adrenal insufficiency: Presentation of a case and review of the literature]. Ann. Med. Interna. 1994, 11, 496–498. [Google Scholar]
  30. Paccalin, M.; Amoura, Z.; Wechsler, B.; Piette, J.C. Une calcification du cartilage auriculaire [Ear cartilage calcification]. Rev. Med. Interne 2000, 21, 295–296. [Google Scholar] [CrossRef] [PubMed]
  31. Wang, C.Y.; Chang, T.C.; Chen, F.W. Ossification of the auricles: A forgotten sign in adrenal insufficiency. J. Otolaryngol. 2002, 31, 52–54. [Google Scholar] [CrossRef]
  32. Agut Fuster, M.A.; Agulles Fornés, M.J.; Ferrer Rodríguez, A.; Ramos Martínez, M.J.; del Campo Biosca, J.; Viel Martínez, J.M. Calcification of auricular cartilages in adrenal insufficiency. Acta Otorrinolaringol. Esp. 2007, 58, 167–168. [Google Scholar] [CrossRef]
  33. Fukushima, K.; Sato, S.; Yamazaki, M.; Kaneko, A.; Oofusa, H.; Yahikozawa, H. Shock and stony hard ears. Lancet 2007, 369, 856. [Google Scholar] [CrossRef]
  34. Thomson, M.A.; Biggs, P.; Berth-Jones, J. Familial petrified ears associated with endocrinopathy. J. Am. Acad. Dermatol. 2007, 57 (Suppl. S5), S121–S122. [Google Scholar] [CrossRef] [PubMed]
  35. Machado, A.; Lopes, M.; Ferreira, C. Petrified auricular cartilages pointing the diagnosis of post-partum hypopituitarism in an encephalopathic patient. Eur. Arch. Otorhinolaryngol. 2009, 266, 305–307. [Google Scholar] [CrossRef]
  36. Mastronikolis, N.S.; Zampakis, P.; Kalogeropoulou, C.; Stathas, T.; Siabi, V.; Geropoulou, E.; Goumas, P.D. Bilateral ossification of the auricles: An unusual entity and review of the literature. Head Face Med. 2009, 5, 17. [Google Scholar] [CrossRef] [PubMed]
  37. Richter, J.C.; Chappuis, B. Ohren “aus Stein”—Ungewöhnlicher Begleitbefund aufgrund einer untersubstituierten Nebenniereninsuffizienz [Ears “made of stone”—Unusual secondary phenomenon of undersubstituted adrenal insufficiency]. Dtsch. Med. Wochenschr. 2009, 134, 1869–1871. [Google Scholar] [CrossRef]
  38. Lee, M.T.; Wang, C.Y. Auricular ossification in adrenal insufficiency. J. Endocrinol. Metab. 2011, 1, 45–46. [Google Scholar] [CrossRef]
  39. Uthoff, H.; Wiesli, P. Images in clinical medicine. Auricular cartilage calcification and adrenal insufficiency. N. Engl. J. Med. 2011, 364, 157. [Google Scholar]
  40. Gogate, Y.; Gangadhar, P.; Walia, R.R.; Bhansali, A. “Petrified ears” with idiopathic adult-onset pituitary insufficiency. Indian J. Endocrinol. Metab. 2012, 16, 830–832. [Google Scholar] [CrossRef]
  41. Koning, M.V.; Struijs, A. Adrenal insufficiency presenting as bilateral rigid auricles: A case report. J. Med. Case Rep. 2014, 8, 302. [Google Scholar] [CrossRef]
  42. Calderón-Komáromy, A.; Córdoba, S.; Tardío, J.C.; Borbujo, J. Osificación bilateral del cartílago auricular (bilateral ossification of the auricular cartilage). Actas Dermosifiliogr. 2015, 106, 433–435. [Google Scholar]
  43. Goswami, S.; Chakraborty, P.P.; Ray, S.; Ghosh, S.; Chowdhury, S. “Petrified ears” in secondary adrenal insufficiency. J. Clin. Diagn. Res. 2016, 10, OD23–OD24. [Google Scholar] [CrossRef]
  44. James, H.A.; Wermers, R.A. “Petrified ears”: Auricular ossification in adrenal insufficiency. Mayo Clin. Proc. 2016, 91, 1487–1488. [Google Scholar] [CrossRef]
  45. Taguchi, T.; Yoshida, M.; Terada, Y. Petrified ear auricles with isolated adrenocorticotropic hormone deficiency. Intern. Med. 2017, 56, 3263–3264. [Google Scholar] [CrossRef]
  46. Sedhai, Y.R.; Basnyat, S. Petrified pinna and pericarditis in autoimmune polyendocrine syndrome. BMJ Case Rep. 2019, 12, e229369. [Google Scholar] [CrossRef]
  47. Kannenberg, S.; Meyhöfer, S.; Lehnert, H.; Schmid, S.M. Petrifying: Ears as hard as stone in adrenal insufficiency. Lancet Diabetes Endocrinol. 2021, 9, 406. [Google Scholar] [CrossRef] [PubMed]
  48. Ozer Ozturk, E.; Karatas, E. Auricular calcification: Case report of petrified ears in a woman. Ann. Medical Res. 2021, 28, 621–623. [Google Scholar] [CrossRef]
  49. Recalcati, S.; Fantini, F. Petrified ears: A clue for adrenal insufficiency. Dermatopathology 2021, 8, 45–48. [Google Scholar] [CrossRef]
  50. Recalcati, S.; Vassallo, A.; Villanova, M.; Lanzi, R.; Losa, M.; Patricelli, M.G.; Carrera, P.; Fantini, F. Growth hormone deficiency and secondary adrenal insufficiency in petrified ear syndrome: A case report and literature review. Dermatol. Rep. 2025, 17, 10263. [Google Scholar] [CrossRef] [PubMed]
  51. Choo, K.S.; Yew, J.; Tan, E.J.H.; Puar, T.H.K. Case Report: Hypercalcemia as a manifestation of acute adrenal crisis precipitated by fluconazole use, and a review of the literature. Front. Endocrinol. 2023, 14, 1168797. [Google Scholar] [CrossRef]
  52. Batson, J.M. Calcification of the ear cartilage associated with the hypercalcemia of sarcoidosis. Report of a case. N. Engl. J. Med. 1961, 265, 876–877. [Google Scholar] [CrossRef] [PubMed]
  53. Riikonen, R.; Simell, O.; Jääskeläinen, J.; Rapola, J.; Perheentupa, J. Disturbed calcium and phosphate homeostasis during treatment with ACTH of infantile spasms. Arch. Dis. Child. 1986, 61, 671–676. [Google Scholar] [CrossRef]
  54. Wexler, L.; Brundage, B.; Crouse, J.; Detrano, R.; Fuster, V.; Maddahi, J.; Rumberger, J.; Stanford, W.; White, R.; Taubert, K. Coronary artery calcification: Pathophysiology, epidemiology, imaging methods, and clinical implications. A statement for health professionals from the American Heart Association. Writ. Group Circ. 1996, 94, 1175–1192. [Google Scholar] [CrossRef]
  55. Verghese, A.; Charlton, B.; Kassirer, J.P.; Ramsey, M.; Ioannidis, J.P. Inadequacies of physical examination as a cause of medical errors and adverse events: A collection of vignettes. Am. J. Med. 2015, 128, 1322–1324.e3. [Google Scholar] [CrossRef] [PubMed]
  56. Ende, J.; Fosnocht, K.M. Clinical examination: Still a tool for our times? Trans. Am. Clin. Climatol. Assoc. 2002, 113, 137–155. [Google Scholar] [PubMed]
Jcm 14 06870 g001
Figure 1. Study Selection Flowchart.
Figure 1. Study Selection Flowchart.
Jcm 14 06870 g001
Table 1. Characteristics of 40 patients, 22 to 79 years of age, with bilateral petrified ear associated with adrenal insufficiency. Data are presented as frequency (and sometimes also as percentage) or as median and interquartile range (individual values if <5 cases).
Table 1. Characteristics of 40 patients, 22 to 79 years of age, with bilateral petrified ear associated with adrenal insufficiency. Data are presented as frequency (and sometimes also as percentage) or as median and interquartile range (individual values if <5 cases).
Adrenal Insufficiencyp-Value
AllPrimaryCentralUnclassified
N4018202
Demographics
Males:females38:218:018:22:00.5385
Age ∆, years56 (44–67)55 (46–70)49 (37–62)60, 700.1917
Concomitant endocrine conditions16 (40)3 (17)11 (55)2 (100)0.0070
Hypothyroidism11 (28) 3 (17)7 (35)1 (50)0.2672
Type 2 diabetes mellitus1 (2.5)001 (50)>0.9999
Hypogonadism5 (13)05 (25)00.0366
Growth hormone deficiency3 (7.5)03 (15)00.0734
Hyperprolactinemia3 (7.5)03 (15)00.0734
Temporal relationship with adrenal disease diagnosis 0.0381
Calcification before by ≥2 years4 (10)2 (11)1 (5.0)1 (50)
Calcification and adrenal disease concurrently19 (48)3 (17)16 (80)0
Calcification after by ≥2 years 17 (43)13 (72)3 (15)1 (50)
Phosphocalcemic factors
Hypercalcemia1 (2.5)01 (5.0)0>0.9999
Hyperphosphatemia1 (2.5)01 (5.0)0>0.9999
Parathyroid hormone level increased0000>0.9999
Vitamin D level increased0000>0.9999
∆ at diagnosis of petrified ear.
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MDPI and ACS Style

Jörg, E.; Milani, G.P.; Lava, S.A.G.; Bianchetti, M.G.; Bronz, G.; Faré, P.B.; Santi, M. Petrified Ear in Adrenal Insufficiency: Systematic Literature Review. J. Clin. Med. 2025, 14, 6870. https://doi.org/10.3390/jcm14196870

AMA Style

Jörg E, Milani GP, Lava SAG, Bianchetti MG, Bronz G, Faré PB, Santi M. Petrified Ear in Adrenal Insufficiency: Systematic Literature Review. Journal of Clinical Medicine. 2025; 14(19):6870. https://doi.org/10.3390/jcm14196870

Chicago/Turabian Style

Jörg, Elisa, Gregorio P. Milani, Sebastiano A. G. Lava, Mario G. Bianchetti, Gabriel Bronz, Pietro B. Faré, and Maristella Santi. 2025. "Petrified Ear in Adrenal Insufficiency: Systematic Literature Review" Journal of Clinical Medicine 14, no. 19: 6870. https://doi.org/10.3390/jcm14196870

APA Style

Jörg, E., Milani, G. P., Lava, S. A. G., Bianchetti, M. G., Bronz, G., Faré, P. B., & Santi, M. (2025). Petrified Ear in Adrenal Insufficiency: Systematic Literature Review. Journal of Clinical Medicine, 14(19), 6870. https://doi.org/10.3390/jcm14196870

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