Branchiootic syndrome is a genetic condition that affects the ears, neck, and sometimes the kidneys. Common signs include pits or cysts on the side of the neck, small openings near the ears, hearing loss, and ear differences that doctors can see on exam. Features are usually present from birth and last lifelong, but they can vary in severity across family members. Many people with Branchiootic syndrome live a normal lifespan, though hearing loss and occasional kidney issues may need care. Treatment focuses on hearing support, surgical removal of bothersome neck or ear cysts, and regular kidney and hearing monitoring.
Overview
Branchiootic syndromeSymptoms
Branchiootic syndrome causes neck pits or cysts, outer ear differences, and hearing loss. Features are usually noticed at birth or early childhood. Early signs of Branchiootic syndrome include preauricular pits, ear tags, and visible neck lumps.
Outlook and prognosis
Most people with Branchiootic syndrome grow up healthy with typical intelligence and near‑normal life expectancy. Hearing differences are common but often manageable with hearing aids or surgery; ear infections may need attention. Kidney checks help catch issues early, guiding long‑term care.
Causes and risk factors
Branchiootic syndrome results from single-gene variants, usually EYA1, and follows autosomal-dominant inheritance. A parent with the variant has a 50% chance to pass it on; some cases are new mutations. Lifestyle or environmental causes aren’t known; features vary.
Genetic influences
Genetics are central in Branchiootic syndrome; it’s usually inherited in an autosomal dominant pattern. Variants in EYA1, SIX1, or SIX5 disrupt ear and neck development. Family history strongly guides risk, while genetic testing confirms the diagnosis and enables targeted counseling.
Diagnosis
Doctors typically suspect Branchiootic syndrome from clinical features and family history, then confirm with genetic tests. Hearing tests and imaging of ears/neck help define findings and support the genetic diagnosis of Branchiootic syndrome.
Treatment and drugs
Treatment for branchiootic syndrome focuses on each feature. Ear infections and hearing loss are managed with hearing aids, ear tubes, or surgery; neck or ear pits and cysts are removed if they drain or get infected. Regular hearing checks and family genetics counseling help plan care.
Symptoms
Branchiootic syndrome affects the ears and neck from birth, most often showing up as hearing differences and small skin pits or cysts. Features vary from person to person and can change over time. Early features of Branchiootic syndrome often include hearing loss in one or both ears, tiny pits or tags near the front of the ear, and small openings or lumps on the side of the neck that may drain.
This can affect one or both ears and ranges from mild to severe. In Branchiootic syndrome, it may come from the outer or middle ear, the inner ear, or both. A child may turn up the TV or sit closer to speakers.
Small skin dimples or little tags can sit just in front of the ear. These are common in Branchiootic syndrome and are usually harmless. They can sometimes get irritated or infected.
Tiny openings or soft lumps along the side of the neck may drain clear or cloudy fluid. They can swell or feel tender during colds or throat infections. Clinicians call this a branchial cleft anomaly, which means leftover tissue from early development formed a small passage or cyst.
The ear may look slightly different in size, fold, or position. These differences do not always affect hearing but often occur with ear pits or tags.
How people usually first notice Branchiootic syndrome?
The first signs of Branchiootic syndrome are often noticed in infancy or early childhood when families see small pits, tags, or cysts along the side of the neck or just in front of the ears, sometimes with drainage from those branchial areas. Doctors may also pick it up because of ear shape differences or hearing loss discovered on the newborn hearing screen or later when a child doesn’t respond to sounds or has delayed speech. In some families, parents recognize how Branchiootic syndrome is first noticed because similar neck or ear features and hearing differences have appeared across generations.
Types of Branchiootic syndrome
Branchiootic syndrome has a few recognized clinical variants, mostly defined by which gene is affected and whether kidney features are present. These variants share a core pattern of branchial (neck) pits or cysts, ear shape differences, and hearing loss, but severity can vary widely even within the same family. Symptoms don’t always look the same for everyone. Understanding the main variants of Branchiootic syndrome can help explain why some people have only ear and neck findings while others also have kidney changes.
BO syndrome
This variant involves branchial pits or cysts and ear differences, with hearing loss that can be conductive, sensorineural, or mixed. It typically does not include kidney problems. Not everyone will experience every type.
BOR syndrome
This includes the same ear and branchial findings as BO, plus kidney differences ranging from mild structural changes to kidney function issues. For many, hearing loss is present from childhood and may be stable or change slowly over time.
EYA1-related
Changes in the EYA1 gene are the most common genetic cause and can lead to BO or BOR features across the same family. Features and severity can differ person to person, even with the same gene change. Doctors sometimes classify symptoms as ear/branchial versus kidney-related.
SIX1-related
Variants in the SIX1 gene usually cause ear and branchial findings and hearing loss, with kidney involvement less common than in EYA1. People may notice different sets of symptoms depending on their situation.
SIX5-related
Changes in SIX5 are a less frequent cause and may show milder or variable features within the BO/BOR spectrum. Some have mainly hearing loss and ear shape differences, while others also develop branchial pits or cysts. When people talk about symptoms, they often mean one of these kinds:
What genetics can tell you about symptoms
Some people with branchiootic syndrome develop pits or cysts near the neck and ears, plus hearing loss, because gene changes (often in EYA1, SIX1, or SIX5) disrupt how the outer ear, middle ear bones, and neck tissues form. Specific variants can tilt symptoms toward conductive, sensorineural, or mixed hearing loss and make ear pits or branchial cysts more likely.
Causes and risk factors
Branchiootic syndrome is caused by a change in a gene that guides development of the ears and neck. Most cases involve EYA1, and some involve SIX1 or SIX5. It is usually inherited in an autosomal dominant way, but some cases arise as a new change with no family history. Risk can vary widely from person to person. The main risk factors for Branchiootic syndrome are an affected parent or a known family gene change, and lifestyle or environment do not appear to cause it.
Environmental and biological risk factors
Branchiootic syndrome begins very early in pregnancy, when the neck and ear structures are taking shape. Doctors often group risks into internal (biological) and external (environmental). Most risk factors for Branchiootic syndrome relate to internal development, and there are no proven outside triggers, but a few exposures can affect the same tissues at the same time. The points below outline environmental and biological elements that may influence likelihood.
Neck and ear tissues form during weeks 4–7 of pregnancy. Disruptions in this period can raise the chance of differences that resemble features of Branchiootic syndrome. Timing matters because these structures are rapidly changing.
Uncontrolled diabetes in early pregnancy is linked to higher rates of congenital differences, including those affecting head and neck development. This biological stress can increase the overall likelihood of related anomalies.
Some acne or psoriasis medicines derived from vitamin A can disrupt branchial arch and ear formation if taken in early pregnancy. While not shown to cause Branchiootic syndrome directly, their effects overlap with the same developing structures.
Significant radiation exposure early in pregnancy can interfere with organ formation. This may increase general birth-defect risk, though specific links to this condition have not been demonstrated.
Genetic risk factors
Branchiootic syndrome often runs in families and is usually caused by changes in one of a small number of genes. Some risk factors are inherited through our genes. Most cases follow an autosomal dominant pattern, which means a parent with the genetic change has a 1 in 2 (50%) chance to pass it to each child. Genetic testing for Branchiootic syndrome can look for changes in EYA1 and, less often, SIX1, and can clarify who in a family carries the risk.
EYA1 gene changes: Changes in the EYA1 gene are the most common known cause. They can be tiny changes in the gene or larger missing pieces of DNA, and features can vary widely between relatives. Some families have Branchiootic syndrome without kidney differences, while others in the same family may also have kidney findings.
SIX1 gene changes: Less often, Branchiootic syndrome is linked to changes in the SIX1 gene. People with SIX1 changes often have ear and hearing features, while kidney differences are less common. Still, findings can range from very mild to more noticeable within the same family.
Autosomal dominant inheritance: Most families show an autosomal dominant pattern—one altered copy is enough to cause the condition. An affected parent has a 50% chance to pass the change to each child. Features can be mild, so a parent may not realize they are affected.
New genetic changes: Sometimes the genetic change happens for the first time in a child, with no prior family history. In those cases, the chance for siblings to be affected is usually low, though rarely, a parent may carry the change in some cells. A genetics team can review recurrence risks for your family.
Variable features: The same genetic change can look very different from person to person. One relative may have only small ear pits, while another has branchial cysts and hearing loss.
Reduced penetrance: Not everyone who inherits the change shows clear features, or they may be so mild they go unnoticed. This can make family history look negative even when a genetic cause is present. Careful exam and targeted testing can uncover subtle signs.
Missing DNA segments: Some people have a small missing segment of DNA that includes EYA1 rather than a single-letter change. These changes may require special lab methods to detect. Finding them can confirm the genetic cause of Branchiootic syndrome in a family.
Lifestyle risk factors
Branchiootic syndrome is a genetic condition; lifestyle habits do not cause it. However, day-to-day choices can influence ear health, hearing trajectory, infection risk, wound healing, and balance. The points below focus on how lifestyle affects Branchiootic syndrome and highlight practical lifestyle risk factors for Branchiootic syndrome.
Loud music, power tools, or concerts can accelerate hearing loss in people with branchiootic anatomy. Consistent use of earplugs or earmuffs helps preserve remaining hearing.
Putting cotton swabs or objects in the ear can injure delicate canals and worsen conductive problems or infections. Gentle external cleaning and professional wax removal lower these risks.
Unprotected swimming or frequent water entry into the ears can lead to otitis, especially if eardrum or canal anomalies are present. Custom swim plugs and drying drops (if advised by a clinician) help prevent infections.
Tobacco and vaping aerosols impair eustachian tube function and slow healing after ear or neck procedures. Avoiding smoke exposure lowers ear infection rates and surgical complications.
Risk prevention
Branchiootic syndrome is genetic, so you can’t prevent the condition itself, but you can lower the chance of complications and protect hearing and communication. Focus on early detection, steady check-ins with ear, nose, and throat (ENT) and hearing specialists, and infection prevention. Noticing early symptoms of Branchiootic syndrome—like small pits or cysts along the side of the neck or changes in hearing—can help families seek care sooner. Prevention works best when combined with regular check-ups.
Make sure hearing is tested right after birth and repeated if needed. Early results guide next steps to protect language development.
Schedule hearing checks regularly, especially through childhood. Catching changes early helps fine‑tune support and reduce learning impact.
Limit loud noise at concerts, sports venues, and with headphones. Use well-fitted ear protection to avoid extra stress on hearing in Branchiootic syndrome.
Keep up with prompt care for ear pain, fever, or drainage to reduce complications. Avoid tobacco smoke exposure and manage allergies to lower infection risk.
Transmission
Branchiootic syndrome is not contagious; you can’t catch it or pass it through everyday contact. Most often, Branchiootic syndrome is inherited in an autosomal dominant way, meaning one altered copy of the gene is enough; if a parent has it, each pregnancy carries a 50% chance that the child will inherit it. The genetic transmission of Branchiootic syndrome can also occur for the first time in a family because of a new gene change, so there may be no prior family history. Features can vary widely, even among relatives, so a parent may be mildly affected while a child has more noticeable signs. If you’re considering family planning, a genetic counselor can explain how Branchiootic syndrome is inherited and discuss testing options.
When to test your genes
Test your genes if you have branchial clefts or cysts near the neck plus ear malformations or hearing loss, or if close relatives have similar features. Genetic results can confirm the diagnosis, guide hearing surveillance and surgical planning, and inform family risks. Consider testing before major ear/neck procedures or pregnancy planning.
Diagnosis
Branchiootic syndrome is typically identified by a pattern of ear differences, hearing loss, and branchial cleft cysts or pits on the neck. Doctors usually begin with a careful exam and a review of hearing history and family patterns. The genetic diagnosis of Branchiootic syndrome often combines what is seen on exam with targeted DNA testing. Imaging may be used to define neck or ear structures and to rule out related conditions that affect the kidneys.
Providers look for small pits or sinuses on the neck, ear shape differences, and scars from prior cyst infections. These clinical features, when seen together, point strongly toward Branchiootic syndrome.
A detailed family and health history can help identify a pattern across generations. Because this condition can run in families, having affected relatives increases the likelihood and supports the diagnosis.
Hearing tests check for sensorineural, conductive, or mixed hearing loss, which is common in Branchiootic syndrome. Results guide treatment plans such as hearing aids or surgical options.
CT or MRI of the temporal bones can show middle or inner ear structure differences that align with this diagnosis. Imaging findings help explain the type of hearing loss and assist with surgical planning if needed.
Stages of Branchiootic syndrome
Branchiootic syndrome does not have defined progression stages. It is present from birth, and features like small neck pits, cysts near the ear, or ear differences tend to remain fairly steady over time, though hearing may stay the same or slowly change for some. When early symptoms of Branchiootic syndrome—such as tiny skin openings on the side of the neck or new hearing concerns—are noticed, different tests may be suggested to help confirm the diagnosis, including a physical exam, hearing checks, and imaging; many teams also review the kidneys to rule out the closely related branchio‑oto‑renal condition. Ongoing care often includes regular hearing evaluations and follow-up with ear, nose, and throat specialists, with genetic testing considered in some families.
Outlook and prognosis
Many people ask, “What does this mean for my future?”, especially after a new diagnosis of Branchiootic syndrome. Most people with Branchiootic syndrome have a normal life span, and the day-to-day impact is usually centered on hearing differences and cosmetic neck or ear features rather than life-threatening complications. Prognosis refers to how a condition tends to change or stabilize over time. Hearing loss can be stable or gradually change across childhood or adulthood, and early symptoms of Branchiootic syndrome—like ear pits, branchial cysts, or mild hearing trouble—often prompt testing and early support.
The outlook is not the same for everyone, but hearing-focused care, speech and language support when needed, and timely surgery for branchial cysts or fistulas can greatly reduce complications. Serious problems such as infections from cysts can occur if they’re not treated, but with standard care the risk of lasting harm is low. In medical terms, the long-term outlook is often shaped by both genetics and lifestyle. Children with Branchiootic syndrome who receive early hearing assessment and amplification, if needed, generally keep pace with school and social development, and adults commonly work and participate fully in daily life.
Not everyone with the same gene change will have the same outlook. Some people experience mild, barely noticeable features, while others notice more significant hearing loss that benefits from hearing aids or, less often, cochlear implants. Mortality is not increased in Branchiootic syndrome itself; life expectancy is typically typical, and most health concerns are manageable with routine follow-up. Talk with your doctor about what your personal outlook might look like.
Long-term effects
Branchiootic syndrome usually has a stable outlook and a normal life expectancy. The biggest long-term issue is hearing, which can range from mild to more noticeable changes over time. Long-term effects vary widely, and even within the same family, features can look different. Many families remember the early symptoms of Branchiootic syndrome showing up in childhood, but the long-term picture often becomes clearer as kids grow into teens and adults.
Hearing loss may be conductive, sensorineural, or mixed. It can stay steady or slowly change across childhood and adulthood.
Early hearing differences can influence speech and classroom participation. Many living with Branchiootic syndrome do well academically once communication needs are recognized.
Outer or middle ear shapes may look different and persist lifelong. These differences in Branchiootic syndrome often explain the hearing pattern seen on tests.
Small pits or sinus tracts along the neck or near the ear can remain or recur over time. They usually don’t affect lifespan but can be a long-term cosmetic concern.
How is it to live with Branchiootic syndrome?
Living with branchiootic syndrome often means planning around hearing differences and occasional ear infections, along with routine skin and neck care for branchial cleft pits or cyst scars. Many find that early hearing support—hearing aids, bone-anchored devices, or classroom accommodations—reduces daily strain at school, work, and in social settings, where background noise can otherwise make conversations tiring. Families and partners usually become skilled teammates, learning clear-communication habits, preparing for medical visits, and watching for changes that need an ENT or genetic follow-up. With these supports in place, most people build steady routines and participate fully in school, careers, sports, and community life.
Treatment and drugs
Treatment for Branchiootic syndrome focuses on the specific features you have, since the condition can affect the ears, hearing, neck area, and sometimes the kidneys. Hearing care is central: timely hearing tests, hearing aids, bone‑anchored devices, or cochlear implants may be recommended, along with speech and language therapy for children to support communication. Neck pits or cysts can be observed if they’re quiet, but recurrent infections or draining tracts are usually managed with antibiotics during flares and surgical removal when needed; ear canal or outer‑ear differences may also be addressed with reconstructive surgery. Kidney checks with ultrasound and blood/urine tests help catch problems early, and a nephrologist guides treatment if kidney function is affected. Not every treatment works the same way for every person, so you might picture this as a team effort between you and your doctor, including audiology, ENT, genetics, speech therapy, and, when needed, kidney specialists.
Non-drug treatment
Branchiootic syndrome often affects hearing and the small structures around the ear and neck, so everyday communication and schooling can be impacted. Non-drug treatments often lay the foundation for clearer communication, safety, and confidence. Spotting early symptoms of Branchiootic syndrome—like trouble responding to sound in infancy or tiny ear pits—can help time the right supports. Care is tailored to age and severity, and it may change over time as needs evolve.
Early and repeat hearing tests track any changes and guide support. Audiology teams use age-appropriate methods, from newborn screening to play-based testing.
Modern devices can amplify speech while reducing background noise. Fitting and fine-tuning are adjusted as hearing changes and as children grow.
For certain outer or middle ear differences, sound can be conducted through the skull. These can be worn on a soft band in young children or implanted later by a surgeon.
If hearing loss is severe and aids do not help enough, an implant can directly stimulate the hearing nerve. A full program of mapping and therapy follows surgery to build listening skills.
Your genes may have an impact on how drugs work for you
Even when two people share the same diagnosis of Branchiootic syndrome, their genes can change how they process medicines—affecting dose needs, benefits, and side effects. Pharmacogenetic testing and careful monitoring help tailor treatments like antibiotics, pain relievers, and anesthetics safely.
Pharmacological treatments
There isn’t a medicine that changes the genes involved in Branchiootic syndrome, so drug treatment focuses on day‑to‑day issues like ear infections, drainage, and pain that affect comfort and hearing. Drugs that target symptoms directly are called symptomatic treatments. For many, this means short courses of antibiotics during flare‑ups and simple pain relief when needed. These medicines often help with problems that show up among the early symptoms of Branchiootic syndrome, such as repeated ear infections or tender, draining neck pits.
Amoxicillin is often used first for acute middle‑ear infections; amoxicillin–clavulanate may be chosen if symptoms are severe or recurrent. A different antibiotic is used if there’s penicillin allergy or recent antibiotic exposure. First-line medications are those doctors usually try first, based on safety, effectiveness, and guidelines.
Ofloxacin otic or ciprofloxacin–dexamethasone drops treat ear canal infections or drainage through a tube or small eardrum opening. Drops place the medicine right where it’s needed and can clear discharge and discomfort efficiently. Your clinician will guide how long to use them to avoid relapse.
Acetaminophen (paracetamol) or ibuprofen can reduce ear pain and fever during infections. Use weight‑based dosing and avoid aspirin for children and teens. Never stop or change a prescription without checking with your healthcare provider.
Infected branchial pits or cysts may be treated with cephalexin; clindamycin is an option if there’s a penicillin allergy. Mild, localized skin infection around a pit may respond to a short course of topical mupirocin. Your care team will choose coverage based on likely skin bacteria and local resistance patterns.
Genetic influences
Branchiootic syndrome often runs in families because a single gene change can cause the condition, and one changed copy is enough to pass it on to a child. Many cases trace back to changes in genes such as EYA1 or SIX1, though a new (first‑time) change can also appear in a child with no prior family history. Family history is one of the strongest clues to a genetic influence. Even within the same family, Branchiootic syndrome can look different—one relative may have mild hearing loss, while another has ear shape differences or small pits or cysts along the neck—so someone may have the gene change and not realize it if their features are subtle. Each child of a person with Branchiootic syndrome has a 1 in 2 (50%) chance of inheriting the gene change. Genetic testing for Branchiootic syndrome and meeting with a genetic counselor can confirm the change, clarify risks for relatives, and guide care across the family.
Is Branchiootic syndrome genetic?
Genetics are central in Branchiootic syndrome; it’s usually inherited in an autosomal dominant pattern. Variants in EYA1, SIX1, or SIX5 disrupt ear and neck development. Family history strongly guides risk, while genetic testing confirms the diagnosis and enables targeted counseling.
Pharmacogenetics—how genetics influence drug effects
For people living with Branchiootic syndrome, care usually centers on hearing support and, at times, surgery; the gene changes that cause the condition don’t typically alter how your liver processes most medicines. Because hearing is involved, your team will try to avoid or closely monitor drugs that can harm the inner ear, such as certain antibiotics (aminoglycosides) or very high doses of some water pills (loop diuretics); a separate inherited mitochondrial change, if present, can make aminoglycoside-related hearing loss much more likely. After procedures, pain medicines like codeine or tramadol depend on a liver enzyme that varies by gene, so some people feel strong effects while others get little relief, and knowing your pattern can help guide safer choices. Genetics is only one factor, though—age, kidney function, and other medicines also shape how a drug works for you. Pharmacogenetic testing for Branchiootic syndrome isn’t routine, but targeted testing can help when specific drugs are being considered, for example to see whether codeine is a good option for you. If there’s any concern for kidney involvement on the broader branchio‑oto‑renal spectrum, your doctor may adjust the dose or select alternatives for medicines that are cleared by the kidneys.
Interactions with other conditions
Ear differences in Branchiootic syndrome can make middle-ear fluid and ear infections more common, which may temporarily worsen hearing or delay progress with hearing devices and speech therapy. Colds, seasonal allergies, and sinus infections can add pressure and fluid in the ears, so some notice hearing fluctuates during these times; early symptoms of Branchiootic syndrome such as ear pits or hearing changes may show up before these patterns emerge. Certain diseases may “overlap,” meaning features of Branchiootic syndrome can blend with the branchio‑oto‑renal spectrum, so many clinicians will check the kidneys at least once to rule out hidden kidney issues. If kidney disease is present for any reason, treatment choices matter because a few antibiotics used for serious infections can affect hearing; your care team can choose safer options when possible. Long-term noise exposure and other causes of hearing loss can add to the hearing challenges from Branchiootic syndrome, so hearing protection and routine hearing checks are important at any age. Interactions can look very different from person to person, and coordinated care between ear, hearing, and (if needed) kidney specialists helps keep the whole picture in view.
How genes can cause diseases
Humans have more than 20,000 genes, each carrying out one or a few specific functions in the body. One gene instructs the body to digest lactose from milk, another tells the body how to build strong bones and another prevents the body's cells from beginning to multiply uncontrollably and developing into cancer. As all of these genes combined are the building instructions for our body, a defect in one of these genes can have severe health consequences.
Through decades of genetic research, we know the genetic code of any healthy/functional human gene. We have also identified that in certain positions on a gene, some individuals may have a different genetic letter from the one you have. We call these hotspots "Genetic Variations" or "Variants" in short. In many cases, studies have been able to show that having the genetic letter "G" in the position makes you healthy, but having the letter "A" in the same position disrupts the gene function and causes a disease. Genopedia allows you to view these variants in genes and summarizes all that we know from scientific research, which genetic letters (Genotype) have good or bad consequences on your health or on your traits.
History
Throughout history, people have described children born with small pits or tags in front of the ears, families in which several relatives were hard of hearing, and, less often, neck lumps that drained in childhood. Grandparents might recall “the ear dimples that run in our family,” while a parent remembers a child’s recurrent neck infections that needed minor surgery. These everyday details trace the long arc of what we now recognize as branchiootic syndrome.
First described in the medical literature as a pattern linking ear differences, hearing changes, and branchial (neck) cysts and fistulas, early reports focused on visible features and family histories. In some eras, each sign was treated as a separate condition, so the full picture was easy to miss. Over time, descriptions became more precise as clinicians compared notes across families and noticed the same trio appearing together, sometimes across several generations.
From early theories to modern research, the story of branchiootic syndrome shows how careful observation evolves into clearer definitions. Once considered rare, now recognized as a spectrum, it includes people with only preauricular pits and normal hearing, as well as those with mild to moderate hearing loss and no neck findings at all. Not every early description was complete, yet together they built the foundation of today’s knowledge.
In recent decades, awareness has grown as advances in genetics confirmed that a change in certain genes can run in families and explain why ear differences, hearing changes, and branchial anomalies tend to cluster. Family studies helped clarify that the condition can be inherited, and that features may vary widely even within the same family. This explained why earlier records sometimes split the diagnosis into parts.
With better newborn hearing screening and more consistent documentation, clinicians began to recognize branchiootic syndrome earlier and more accurately. Historical differences highlight why some adults remember years of separate appointments for “ear pits,” “ear infections,” or “a neck cyst,” while children today are more often evaluated for the combined pattern.
Knowing the condition’s history helps explain current care: today’s approach brings together ear, hearing, and neck evaluations, with genetic counseling offered when helpful. The path from scattered case notes to a named syndrome took decades, but it means that people living with branchiootic syndrome now benefit from coordinated care and clearer information to share with their families.