Dr Hoffers Diagnostic Testing Protocol

Comprehensive Diagnostic Testing Protocol for Suspected Havana Syndrome Cases

This guide outlines the step-by-step diagnostic process used by Dr. Michael Hoffer and his team for evaluating individuals suspected to have suffered from Havana Syndrome. The protocol emphasizes objective neuro-vestibular and cognitive assessments that can be conducted in clinical or field environments.

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🔢 1. Initial Screening Protocol

Objective: Establish baseline symptoms and screen for red-flag indicators of neurovestibular dysfunction.

Required Tools:

• Patient intake forms
• Symptom inventory checklist (e.g., dizziness, tinnitus, ear pain, cognitive fog)
• Interview template for exposure history (onset, location, perceived auditory/pressure sensations)

Steps:

1. Conduct a structured interview documenting:
   • Exact location and time of exposure
   • Sensory descriptions (e.g., high-frequency noise, pressure wave)
   • Immediate symptoms (ear pain, dizziness, cognitive changes)
2. Administer standard questionnaires:
   • Dizziness Handicap Inventory (DHI)
   • Neurobehavioral Symptom Inventory (NSI)
3. Determine eligibility for full diagnostic battery based on symptom severity and acuity.

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🔧 2. Vestibular & Balance Testing

Objective: Quantify vestibular system integrity using inner-ear function tests.

Tests & Tools:

• Subjective Visual Vertical (SVV):
  • Tool: SVV test app or digital plumb line alignment system
  • Procedure: Patient aligns a tilted bar to perceived vertical
  • Abnormal Result: >±3.2° deviation = likely otolith dysfunction
• Vestibular-Evoked Myogenic Potentials (VEMP):
  • Tool: VEMP system (cVEMP and oVEMP)
  • Procedure: Deliver auditory stimulus and record muscular response
  • Abnormal Result: Asymmetry or absence of waveform
• Rotational Chair Testing:
  • Tool: Computerized rotation system (if available)
  • Measures: Semicircular canal function and gain/asymmetry

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👀 3. Eye Movement Testing (Oculomotor Battery)

Objective: Detect dysfunction in vestibulo-ocular and cortical eye movement control.

Tool: Infrared Video-Oculography (VOG) Goggles with VR-based visual tasks

Tests Include:

• Smooth Pursuit & Saccades:
  • Patient tracks moving targets; record latency, overshoot, or hypometria
• Optokinetic Nystagmus (OKN):
  • Strip pattern rolls across screen; detect rhythmic eye response
• Anti-Saccade Task:
  • Patient instructed to look opposite of stimulus; errors indicate frontal executive dysfunction
• Vergence Testing:
  • Measure ability to converge/diverge on a near target; pupil constriction recorded
  • Havana patients showed distinct pupil/eye coupling pattern

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🎤 4. Audiological Testing

Objective: Rule out middle ear or hearing dysfunction

Tools:

• Audiogram (pure-tone)
• Tympanometry
• Otoacoustic Emissions (OAE)

Procedure:

1. Conduct air and bone conduction tests
2. Check middle ear pressure and eardrum movement
3. Evaluate cochlear hair cell function via OAE

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🪠 5. Cognitive & Neurological Assessment

Objective: Identify subtle cognitive impairments and distinguish injury profile

Conducted by: Neuropsychologist or trained clinician using standardized tools

Battery Includes:

• Memory and concentration tasks (e.g., digit span, verbal recall)
• Visuospatial skills
• Executive function (e.g., Stroop, Trail Making Test)
• Anti-saccade error rate (cross-referenced with eye tracking)

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📈 6. Diagnostic Criteria & Scoring

Positive Diagnostic Indicators:

• Abnormal SVV (>3.2°)
• Failed or asymmetric VEMP responses
• Anti-saccade error rate >43%
• Distinct vergence/pupil coupling pattern
• Cognitive impairments that deviate from TBI baseline

Rule-Out Indicators:

• Absence of all vestibular and cognitive deficits
• Test results within control norms

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💸 Equipment Cost Breakdown (Estimated 2025 Pricing)

Tool	Estimated Cost (USD)	Notes
Infrared Video-Oculography (VOG) goggles with VR software	$5,000–$9,000	Portable, field-deployable model
Subjective Visual Vertical (SVV) testing software/app	$200–$800	Some clinics use custom-built rigs
VEMP system (cVEMP/oVEMP)	$10,000–$20,000	Requires EMG sensors and calibration
Rotational Chair (computerized)	$60,000–$120,000	Optional, often hospital-based
Audiometer (Pure-tone testing)	$2,000–$5,000	Basic diagnostic unit
Tympanometer	$1,500–$3,500	Middle ear diagnostics
Otoacoustic Emissions (OAE) equipment	$4,000–$8,000	Cochlear testing device
Cognitive Testing Suite (paper/computer)	$500–$1,500	Can use NIH Toolbox or similar
Laptop for data logging + analysis	$800–$2,000	Required for field diagnostics

Total minimum setup (clinic version): ~$25,000–$35,000
Advanced full lab setup: ~$100,000+ (includes rotational chair)

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⚖️ Interpretation and Use

This protocol is field-adaptable and designed to work in embassy clinics, mobile triage units, or outpatient centers. It prioritizes rapid objective screening and is suitable for:

• Diplomatic security events
• Intelligence personnel evaluations
• Civilian reports of directed exposure symptoms

Always cross-validate with environmental factors and imaging (if available) and track progression over 6–12 months with repeat testing.

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✅ Tests Commonly Available at Specialized Clinics

Test	Where You Can Get It	Notes
Audiogram & Tympanometry	ENT clinics, audiology centers	Widely available, standard tests
Otoacoustic Emissions (OAE)	Pediatric audiology, vestibular centers	Ask specifically for OAE, not all hearing clinics offer it
Vestibular-Evoked Myogenic Potentials (VEMP)	Vestibular specialty clinics, university hospitals	Often only in balance disorder clinics or neuro-otology departments
Subjective Visual Vertical (SVV)	Vestibular rehab clinics, academic hospitals	May be part of post-concussion evaluation protocols
Cognitive Neuropsych Testing	Neuropsychologists, TBI recovery centers	Must request full battery with executive function and memory
Rotational Chair Testing	Advanced balance disorder centers	Very expensive; often requires referral
Eye Tracking (Video-Oculography / Anti-Saccade)	Sports concussion centers, research institutions	Not all use VR-based systems—ask for infrared eye tracking, saccade/anti-saccade, and vergence testing

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⚠️ What You Need to Watch Out For

• Fragmentation: No single clinic offers all of these tests unless it specializes in traumatic brain injury or vestibular research. You may need to go to 3–5 locations.
• Terminology Confusion: Many doctors won’t be familiar with “Havana Syndrome” testing. Instead, ask for tests by their technical names (e.g., “VEMP,” “video-oculography,” “SVV”).
• Gatekeeping: Some tests (e.g., rotational chair or anti-saccade testing) require a referral or insurance pre-auth. A neurologist or neurotologist can help with access.
• Insurance Coverage: Tests like SVV and VEMP are often billed under dizziness or vestibular disorder codes. Use “sudden onset vertigo and cognitive changes” as your working diagnosis if appropriate.

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🔍 Strategy to Access All Tests Through Third Parties

1. Start with a Neurotologist (ENT + Neurology)
   • They can order SVV, VEMP, OAE, audiograms, and refer you to balance labs.
2. Visit a Sports Concussion or Vestibular Rehab Clinic
   • These often have portable eye-tracking goggles and cognitive screeners similar to what Dr. Hoffer used.
3. Request Full Neuropsychological Testing
   • Must include executive function, working memory, visuospatial, and reaction time metrics (e.g., anti-saccade).
4. Ask for Printed or Digital Results

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Disclaimers:

• This guide is based on peer-reviewed methods pioneered by Dr. Michael Hoffer and adapted for accessibility.
• Not a substitute for full neurological or psychiatric workup where indicated.