How is titubation managed?

Management of Titubation

Titubation management focuses on treating the underlying neurological disorder while providing supportive care to prevent respiratory complications and optimize patient safety, particularly regarding airway management.

Identify and Treat the Underlying Cause

Titubation is a symptom of underlying neurological disease rather than a primary disorder, so management must target the root cause:

• Guillain-Barré syndrome variants (including Fisher syndrome and pharyngeal-cervical-brachial variant) may present with truncal titubation and respond to intravenous immunoglobulin therapy, though combined IVIg and steroid therapy may be more effective in complicated cases with multiple antibodies 1
• Multiple sclerosis can cause head titubation severe enough to produce oscillopsia, likely from impaired vestibulo-ocular reflex mechanisms 2
• Joubert syndrome presents with characteristic horizontal head titubation in infancy (typically recognized within first 2 months), which is benign, high-frequency (~3Hz), small amplitude (5-10°), and spontaneously resolves over time 3
• Rett syndrome may manifest with head and truncal titubation as part of the broader clinical picture 4

Airway Management Considerations

Patients with titubation must be considered at higher risk for airway complications and should be approached as potentially having a difficult airway, particularly when associated neurological deficits are present 5:

• Pre-oxygenation is vital before any airway manipulation due to potential for rapid desaturation in neurologically compromised patients 5
• If intubation becomes necessary, assemble the most experienced airway team and prepare for potential complications including "can't intubate, can't oxygenate" scenarios 5
• Consider smaller endotracheal tubes to facilitate passage if airway edema or anatomical distortion is present 5

Supportive Care Measures

Positioning and Respiratory Support

• Position the patient with head elevated at 30 degrees to optimize respiratory function and reduce aspiration risk 5
• Administer high-flow humidified oxygen to maintain SpO2 ≥94% if respiratory compromise develops 5
• Implement respiratory physiotherapy to prevent complications such as atelectasis, particularly in patients with limited mobility 5

Mobilization and Rehabilitation

• Encourage early mobilization to prevent deterioration in neurological and respiratory function 5
• Physical therapy should focus on balance training and gait stabilization when truncal titubation affects ambulation 1, 6

Monitoring and Follow-up

• Continuous monitoring is essential for patients with severe titubation, as neurological symptoms may worsen before improving 1, 6
• In Guillain-Barré variants, CSF protein levels may continue to rise significantly (up to 760 mg/dl) even after symptom onset, and recovery may take months 6
• For infantile head titubation in Joubert syndrome, reassure families that this is benign and self-limited, typically resolving spontaneously without interfering with neurodevelopment 3

Critical Pitfalls to Avoid

• Never overlook potential airway complications in patients with neurological disorders presenting with titubation, as this can lead to increased morbidity and mortality 5
• Do not neglect respiratory care and mobilization, as this leads to secondary complications like atelectasis 5
• Avoid dismissing head titubation in hypotonic infants without careful evaluation for Joubert syndrome, as early recognition prevents unnecessary investigations 3
• In Guillain-Barré variants with titubation, do not assume IVIg alone will be sufficient; consider combined IVIg and steroid therapy for complicated presentations with multiple antibodies 1