In a patient who has had no improvement in steroids after 2 weeks of use will not benefit from an increase in dose of steroid Also vasodilators and ACTH have no role in management of Bells palsy Hence they are also ruled out. So now we are left with 2 options vizi. Electrophysiological nerve testing ii. Surgical decompression Nerve decompression – Surgical management of acute facial nerve palsy is based on the principle that axonal ischemia can be reduced by decompression of nerve segments presumed to be inflamed and entrapped. Nerve decompression is not done in all cases of acute facial palsy. Prerequisite for Nerve decompression (Read very carefully) To identify those patients who may benefit from nerve decompression, electro physiological testing should be done prior to it (Current otolaryngology 3/e, p887) The test done is – Evoked electro myograpy (EEMG). Surgical treatment is offered when evoked response amplitudes are 10% (or less) of the normal side. So now after understanding all this lets see the question once again – It says – a case of bells palsy on steroids, shows no improvement after 2 weeks, next step in management would be - Next step would obviously be electrophysiolgical testing for two reasons: 1. Bells palsy as a rule recovers after 10 days and responds after sterioid, the diagnosis has to reviewed to rule out other causes like herpes zoster oticus (which can be indicated by the pattern of degeneration on electro physiological nerve testing) 2. If electro physiological testing predicts poor prognosis for recovery. It is an indication for nerve decomppression.