This information will help you prepare for radiation therapy to the head and neck, including what to expect before, during, and after your treatment.
You will be getting a type of radiation therapy called external beam radiation. A beam of radiation will be directed to the tumor site from a treatment machine. The beam passes through your body and destroys cancer cells in its path. Below is a picture of the head and neck area (see Figure 1). Your nurse will show you what area will be treated.
Figure 1: Structures of the head and neck
Your Treatment Team
Before your treatment begins, you will need to see a number of specialists who will all be involved in your care. Many of these specialists will see you during and after your treatment.
- Your radiation oncologist will plan your radiation therapy.
- Your medical oncologist will manage your care with your radiation oncologist during and after your treatment.
- Your dentist will check your teeth and explain how radiation will affect your mouth. You must see your dentist before your simulation (this procedure is described below). He or she will check your teeth for problems and do any work that may be needed. Your dentist will also prescribe special toothpaste that contains fluoride to help prevent cavities. If you have a lot of fillings, your dentist may make a rubber mouth guard for you. It fits over your teeth to prevent the metal in the fillings from irritating your mouth. The mouth guard must be made before your simulation. You will need to pick it up from your dentist and bring it to your simulation.
- Your swallowing specialist will check to see how well you can swallow. Swallowing can become difficult during treatment. This specialist will teach you how to do exercises to keep your swallowing muscles strong.
- Your dietitian will help you chose the right foods and liquids. You will need foods that are high in nutrition and easy to swallow. He or she will contact you during the first 2 weeks of your treatment.
- You may need to see a gastroenterologist to discuss placing a feeding tube. You may need to have one placed to help you get enough calories during your treatment. It will be taken out when you do not need it any longer. Your nurse will teach you how to use the tube and will order the supplies for you.
- You may need to meet with a tobacco cessation nurse. If you smoke now, it is important for you to stop. Smoking is a risk factor for head and neck cancer.
Before you begin treatment, you will have a treatment planning procedure called a simulation. This is done to make sure that:
- Your treatment site is mapped out
- You get the right dose of radiation
- The dose to nearby tissue is as small as possible
Your simulation will take about 4 hours.
Preparing for your simulation
- Depending on the type of scans you will need during simulation, your doctor or nurse may tell you not to eat or drink before your simulation.
- If you think you will be uncomfortable while lying still for a long time, bring acetaminophen (Tylenol®) or your usual pain medication to your simulation. Take it 1 hour before your procedure. If you think you may get anxious during your procedure, speak with your doctor about whether medication may be helpful.
- If your dentist made mouth guards for you, pick them up and bring them to your simulation.
The day of your simulation
Wear comfortable clothes. Do not wear earrings or necklaces.
When you arrive for your simulation, your radiation therapist will greet you. He or she will take a photograph of your face. This picture will be used to identify you throughout your treatment.
Your therapist will then explain the procedure to you. If you have not already signed a consent form, your doctor will review it with you, and ask for your signature. Your therapists will not begin the simulation without your permission.
You will get undressed from the waist up and change into a gown. You can keep your shoes on.
During your simulation
Your therapist will walk you to the machine and help you lie on the table. Although the table will have a sheet on it, it is hard and has no cushion. If you haven’t taken pain medication and think you may need it, tell your therapists before your simulation begins. Also, the room is usually cool. If you feel uncomfortable at any time, let your therapists know.
Throughout your simulation, you will feel the table move to different positions. The lights in the room will turn on and off and you will see red laser lights on each wall. Your therapists use these laser lights as a guide when they position you on the table. Do not look directly into the red beam because it may hurt your eyes.
Although your therapists will walk in and out of the room during your simulation, there will always be someone who can see and hear you. You will hear your therapists speaking to each other as they work. They will explain what they are doing, but please do not speak once they begin because it may change your position. However, if you are uncomfortable or need assistance, tell your therapists. To help pass the time, your therapists can play a CD for you. You can bring one of your own from home, if you wish.
You will be lying on your back during your simulation and each treatment. To help you stay in the correct position, you will wear a mask that attaches to the table. Your therapists will make it for you.
To make the mask, your therapists will place a warm, wet sheet of plastic mesh over your face while you are lying on the simulation table. They will then shape it to fit around your head (see Figure 2). You won’t have any trouble seeing or breathing while the plastic mesh is over your face. The mesh will have openings for your eyes and nose.
Figure 2: Mask
As the mask cools, it will harden. You will feel some pressure as your therapists fit the mask to your face. If you feel uncomfortable at any time, tell your therapists. It will take about 15 minutes for the mask to harden.
During your simulation, and every day of your treatment, the mask will be put on your face. It will be secured to the table on which you are lying. This helps ensure that you are in the correct position during each treatment.
Depending on the area to be treated, your therapists may make a bite block for you. They will place a softened piece of plastic on your tongue and ask you to bite it for a few minutes until it hardens. You will use it during each treatment to limit your swallowing.
If your dentist made mouth guards for you, you will also wear these during your simulation and each treatment.
You will wear your mask while images are taken of the area to be treated. These will be done on a computed tomography (CT) scan machine and may also be done with an x-ray machine called a simulator. Sometimes, CT scans are done in the Department of Radiology.
If you are having a CT scan, your nurse may start an intravenous (IV) line to give you contrast, or dye, before the scan. The contrast allows us to get clear images of the area to be treated. These scans are used only to plan your treatment. They are not used for diagnosis or to find tumors. Some patients may also have a positron emission tomography (PET) scan and/or magnetic resonance imaging (MRI). If you are going to have a PET scan and/or MRI, you nurse will give you separate instructions. Please follow them carefully.
Depending on the area that will be treated, you may be asked to grab special straps that push your shoulders down during the imaging. This ensures that your shoulders are out of the area of treatment.
During the scan, you will hear the machines as they turn on and off. Even if the noise seems loud, your therapists will be able to hear you if you need to speak with them. All scans will take about 4 hours.
Skin markings (tattoos)
Your therapists will draw on your skin with a felt marker. Then, they will make permanent skin markings, called tattoos, with a sterile needle and a drop of ink. These may be placed on your mask or on your skin. The sensation of getting a tattoo feels like a pinprick. The tattoo marks are no bigger than the head of a pin. You can wash the felt markings off after your simulation. The tattoos are permanent and will not wash off. If you’re concerned about receiving tattoos as part of your radiation treatment, talk with your doctor.
After the tattoos are made, your therapists will take several photographs of you in your simulation position. The photographs and tattoo marks will be used to position you correctly on the table each day of your treatment.
After Your Simulation
At the end of your simulation, we will schedule you for your set-up procedure. This is the final appointment before your treatment begins. You will also be assigned to a machine for your daily treatment.
During the time between your simulation and your set-up procedure, your radiation oncologist will work with a team to plan your treatment. They will use the images taken during your simulation to plan the angles and shapes of your radiation beams. They will also determine the dose of radiation that you will receive. These details are carefully planned and checked. This process takes between 5 days and 2 weeks.
At the end of your simulation, your therapist will ask you what time of day you would like to have your treatments. We will try to give you the time you like. However, we need a 2-hour window because the time you prefer may not be open. We will move you to that time slot once it opens up. Please know that we will do our best to give you the appointment time you want as soon as we can. The appointment for the following week is usually given on Friday. The Radiation Oncology Department is open from 7:00 am to 7:00 pm.
Radiation treatment is given daily, Monday through Friday, for about 7 weeks. You will be in the department for about 1 hour each day. If additional time is needed due to unforeseen circumstances, your radiation oncologist will tell you. Make sure you come to every appointment because treatment may not be as effective if you skip or miss appointments. If you need to change your schedule for any reason, please speak with your therapists.
Some patients get chemotherapy and radiation treatment on the same day. Chemotherapy can be given before or after your radiation therapy. The timing does not matter.
Before your first treatment, you will have a set-up procedure. This procedure usually takes about 1 hour. If pain or anxiety medication was helpful during your simulation, you may want to take it before this procedure.
When you come for your set-up procedure, you will be shown to the dressing room and asked to undress from the waist up and change into a gown. Your therapists will bring you to the room where you will receive your treatment each day. They will position you on the table. You will lie exactly as you did the day of your simulation. Beam films (x-rays of each of the radiation beams) will be taken to make sure that your position and the area being treated are correct. The beam films will be repeated throughout your treatment. They are not used to see how your tumor responds to treatment. You will usually start your first treatment the day after your set-up procedure.
During Your Treatment
After you check in at the reception desk, have a seat in the waiting room. When they are ready for you, your therapists will ask you to change into a gown.
In the treatment room, your therapists will help you lie on the table and put on your mask. Once you are positioned correctly, they will leave the room, close the door, and begin your treatment. You will not see or feel the radiation, but you may hear the machine as it moves around you and is turned on and off. You will be in the treatment room for 20 to 30 minutes. Most of this time will be spent putting you into the correct position. The actual treatment only takes a few minutes.
Although you are alone during your treatment, your therapists can see you on a monitor and hear you through an intercom at all times. Breathe normally during your treatment, but do not move. If you are very uncomfortable and need help, speak to your therapists. They can turn off the machine and come in to see you at any time, if necessary.
Weekly visits during your treatment
Your radiation oncologist and radiation nurse will see you each week to evaluate your response to treatment. This visit will be before or after your treatments each ________________. You should plan on being in the department about 1 extra hour on those days.
During these visits, you should ask questions and discuss any concerns you have. If you need to speak with your radiation oncologist or radiation nurse any time in between these weekly visits, ask the support staff or therapists to contact them when you come in for treatment.
Most patients develop side effects from radiation therapy. They begin about 2 weeks after treatment starts. They may get worse during treatment, but will slowly get better after treatment is finished. The type and how severe they are depend on many factors. These include the dose of radiation, the number of treatments, and your overall health. Side effects may be worse if you are also getting chemotherapy.
Below are the most common side effects of radiation therapy to the head and neck. You may have all, some, or none of these. Your nurse will discuss the ones you are most likely to have. Please report any problems to your doctor or nurse.
Changes to the mouth and throat
You will notice changes in your mouth and throat that may include:
- Mouth sores
- Mouth pain
- Throat sores
- Throat pain
- Pain with swallowing
- Difficulty swallowing
- Thickened saliva with dry mouth
- Changes in taste
To help relieve these symptoms, follow the suggestions below:
- Brush your teeth after eating and at bedtime with the toothpaste your doctor prescribed for you or with a mild toothpaste that contains fluoride (e.g., Bioténe®). Use a soft-bristle toothbrush. If your mouth becomes too sore for this, use a supersoft or baby’s toothbrush.
- If you have dentures, a bridge, or a dental prosthesis, remove and clean it each time you clean your mouth. Leave it out while you sleep. If your mouth becomes irritated, keep it out of your mouth as much as you can.
- If you currently floss your teeth, continue to floss once a day at bedtime. If you have not flossed in the past, do not begin during your treatment.
- Rinse your mouth with solution every 4 to 6 hours or more often for comfort. Swish and gargle well for 15 to 30 seconds and then spit it out. Use any of the following solutions below:
- One quart (4 cups) of water mixed with 1 teaspoon of salt and 1 teaspoon of baking soda
- One quart of water mixed with 1 teaspoon of salt
- One quart of water mixed with 1 teaspoon of baking soda
- A mouthwash with no alcohol or sugar, e.g., Bioténe®, Dentek™
- Use a lip moisturizer (e.g., Aquaphor®) after you care for your mouth. Do not apply it 4 hours before your treatment.
- If you are experiencing dry mouth, try the suggestions below:
- Try using mouth moisturizers to help relieve the dryness.
- Take frequent sips of water or other liquids (e.g., coconut water, almond milk, Gatorade®, broth) throughout the day. You may find it helpful to carry a bottle of water.
- Use an aerosol pump spray bottle to moisten your mouth throughout the day.
- Use a humidifier at home, especially at night. Avoid using air conditioners. Be sure to change the water in the humidifier and clean it as directed.
- If you start having pain or difficulty swallowing, tell your doctor or nurse. They can prescribe medication to make you more comfortable.
- As side effects develop, your doctor may ask you to be seen daily by your nurse. He or she will inspect the inside of your mouth each day and will spray your mouth, if needed.
Changes inside the nose
You may notice changes inside your nose. These may include:
- Occasional minor nosebleeds
To help relieve these symptoms, keep the inside of your nose moist. You can do this with:
- Saline nose spray
- A humidifier
You may develop pain in your ear from the swelling caused by radiation. Tell your doctor or nurse if you develop ear pain. The pain may be a sign of infection. To take care of your ears:
- Do not use Q-tips®.
- Do not try to clean or clear out your ear.
You may develop hoarseness during your treatment from the swelling caused by radiation. To help relieve these symptoms:
- Rest your voice as much as you can.
- Do not whisper. This can cause strain on your vocal cords.
- Use a humidifier.
- Gargle with one of the solutions mentioned on page 10.
During radiation therapy, your skin in the area being treated will change. After 2 or 3 weeks, your skin will become pink or tanned. As treatment goes on, it may become bright red or very dark. It may also feel dry and itchy and look flaky. You may notice a rash, especially in any area where you have had previous sun exposure. Although this may be a side effect of treatment, a rash could be a sign of an infection. If you develop a rash at any time during your treatment, tell your doctor or nurse.
Sometimes the skin in sensitive areas, such as behind the ear and near the collarbone, may blister, open, and peel. If this happens, tell your doctor or nurse. Your nurse will apply special dressings or creams and teach you how to care for your skin.
The skin reactions sometimes become more severe during the week after treatment is completed. If this happens, call your doctor or nurse. These symptoms will gradually decrease about 3 or 4 weeks after you finish your treatment.
Below are guidelines to care for your skin during treatment. Continue to follow them until the skin reaction resolves. These refer to the skin only in the area being treated.
Keep your skin clean
- Bathe or shower daily using warm water and a mild, unscented soap. Examples of soaps you can use include Neutrogena®, Dove®, baby soap, Basis®, and Cetaphil®. Rinse your skin well and pat it dry with a soft towel.
- When washing, be gentle with your skin in the area being treated. Do not use a washcloth or a scrubbing cloth or brush.
- Do not use alcohol or alcohol pads on the skin in the area being treated.
Moisturize your skin often
- If you are likely to get a skin reaction, your nurse will recommend that you start using a moisturizer. You should start using it the first day of your treatment to minimize the reaction. If you are not likely to develop a skin reaction, you will not need a moisturizer unless your skin becomes dry or itchy. Your nurse will give you instructions. If you are not sure whether you should use a moisturizer, please ask your nurse.
- There are many moisturizers you can use. Some can be purchased over the counter and some require a prescription. There is no evidence that any one moisturizer is better than another. Over-the-counter moisturizers you can use include Aquaphor®, Eucerin®, or calendula.
- If you don’t like the feel of the moisturizer your doctor or nurse recommends, let them know. He or she can select another product for you to try.
- Apply the moisturizer at least 2 times a day.
- If your radiation treatment is in the morning, apply it:
- After your treatment
- Before you go to bed
- If your radiation treatment is in the afternoon, apply it:
- In the morning before your treatment
- Before you go to bed
Avoid irritating your skin in the treatment area
- Wear loose-fitting, cotton clothing over the treated area.
- Use only the moisturizers, creams, or lotions that are recommended by your doctor or nurse.
- Do not use any of the following in the area being treated:
- You can use nonaluminum-based deodorant on intact skin in the area being treated. Stop using it if your skin becomes irritated. Examples of these deodorants include Toms of Maine® and crystal deodorants.
- Avoid shaving the treated skin. If you must shave, use only an electric razor.
- Do not put any tape on the treated skin.
- Do not let your treated skin come into contact with extremly hot or cold temperatures. This includes hot tubs, water bottles, heating pads, and ice packs.
- Do not apply any patches to the treated area, including pain patches.
- If your skin is itchy, do not scratch it. Ask your nurse for recommendation on how to relieve the itching.
- If you have no skin reactions, you can swim in a chlorinated pool. However, be sure to rinse off the chlorine right after getting out of the pool.
- Avoid tanning or burning your skin during and after you are finished with treatment. If you are going to be in the sun, use a PABA-free sunblock with an SPF of 30 or higher. Also, wear loose-fitting clothing that covers you as much as possible.
- If you have any silver-containing bandages, remove them and clean the area before treatment.
You may lose some or all of the hair on your face, neck, or scalp in the area being treated. The hair will usually grow back 2 to 4 months after treatment is completed.
Difficulty with eating and drinking
Radiation to the head and neck can cause pain in your throat, dry mouth, thick saliva, or pain with swallowing. Because of this, you may not be able to eat enough food to maintain your weight and energy level. In addition, if you have a mask to position you for treatment, it may not fit correctly if your weight changes. You also may not be able to drink enough liquid to stay well hydrated. The recommendations below will help you get enough food and liquids.
Get adequate nutrition during your treatment
- Eat a well-balanced diet high in calories and protein. Eating well will help you maintain your weight and feel better during treatment. Your dietitian will work with you to help you select the best foods and liquids.
- If you want more information about eating during treatment, ask your nurse or dietitian for the following resources:
You may take a daily multivitamin if you want. It should not exceed the recommended daily amount. Do not take any other vitamins or nutritional or herbal supplements unless your doctor approves them.
If you are getting chemotherapy at the same time as your radiation therapy, you may need to have a feeding tube placed before beginning treatment. This will ensure you are able to take in enough liquids and nutrients once your side effects begin and it becomes difficult to swallow. You may need to have a feeding tube placed during or after your treatment if you are losing too much weight.
Adjust what you eat and drink based on your side effects
- If you have pain or soreness in your mouth or throat or are having difficulty swallowing:
- Eat soft, moist, bland foods taken in small bites and chewed well.
- Use sauces and gravies to soften foods.
- Avoid substances that may irritate your mouth and throat such as:
- Very hot foods and liquids
- Dry, hard, and coarse foods (e.g., chips, pretzels, crackers, and raw vegetables)
- Spices (e.g., pepper, chili, horseradish, hot sauce, curry)
- Acidic or citrus foods and juices (e.g., orange, grapefruit, lemon, lime, pineapple, tomato)
- Try changing the texture of your foods by blending or puréeing them.
- Take liquid nutrition supplements. There are many products available and they come in a variety of flavors. Speak with your doctor, nurse, or dietitian about how to select a product.
- If your mouth is dry:
- Rinse your mouth before eating.
- Use gravies and sauces to prepare your food.
- Drink liquids while eating dry foods such as rice or bread.
- If you have a loss of appetite:
- Eat small, frequent meals throughout the day. If you never seem to feel hungry, set up a schedule to ensure that you eat regularly.
- Be selective about what you eat. Choose foods and drinks that are high in calories and protein.
- Eat your meals in a calm place and take your time. Eat with family or friends whenever possible.
- Bring snacks and drinks with you when you come for treatment. You can have them while you are waiting or while you are coming to and from the department each day.
- Take liquid nutritional supplements if you are not eating enough food. There are many products available and they come in a variety of flavors. Speak with your doctor, nurse, or dietitian about which product is best for you.
- If you have nausea:
- Tell your doctor or nurse. Medication can be prescribed to relieve this.
- Select foods that are usually well tolerated, including:
- Foods at room temperature or cooler
- Liquids that are cooled or chilled
- Dry, starchy foods such as toast, soda crackers, melba toast, dry cereal, pretzels, and angel food cake
- Yogurt, sherbet, and clear liquids (e.g., apple juice, Jell-O®, ginger ale)
- Cold chicken or turkey, baked or broiled, with the skin removed
- Soft fruits and vegetables
- Avoid foods and liquids that may increase nausea. These include:
- Hot foods with strong odors
- Spicy, fatty, greasy, and fried foods
- Very sweet foods
- Acidic or citrus foods and juices (e.g., orange, grapefruit, pineapple, tomato)
Most people develop fatigue (i.e., lack of energy, sleepiness, weakness, and not being able to concentrate) after 2 or 3 weeks of treatment. This will gradually go away after your treatment is done, but can last for several months. There are a lot of reasons people develop fatigue during treatment, including:
- The effects of radiation on the body
- Traveling to and from treatment
- Not having enough restful sleep at night
- Not eating enough protein and calories
- Having pain or other symptoms
- Feeling anxious or depressed
Some people find that their fatigue is worse at certain times of the day. Below are suggestions to help you manage your fatigue.
- If you are working and are feeling well, continue to do so. However, working less may help increase your energy.
- Plan your daily activities. Pick those things that are necessary and most important to you and do them when you have the most energy.
- Plan time to rest or take short naps during the day, especially when you feel more tired. You may also find it helpful to go to sleep earlier at night and get up later in the morning.
- Ask family and friends to help you with shopping, cooking, and cleaning.
- Some people have more energy when they exercise. If your doctor approves, try light exercise such as walking.
- Eat foods that are high in protein and calories.
- Some people have symptoms such as pain, nausea, diarrhea, difficulty sleeping, or feeling depressed or anxious. These can all increase your fatigue. Ask your doctor or nurse for help with any other symptoms you may have.
If you are getting chemotherapy at the same time as radiation therapy, you will feel very fatigued during the last few weeks of treatment. This, combined with the other side effects you will have, will cause you to feel very weak. During the last 2 weeks of treatment, you may need to have someone come with you each day for your treatment.
There is nothing radioactive inside your body. You cannot pass radiation to anyone else, so there is no need to avoid close contact with other people.
You do not have to change your sexual activity unless your doctor gives you other instructions. However, if you are of childbearing age, you must use contraception so you or your partner will not get pregnant during your treatment.
You may have concerns about the effects of cancer on your sexuality. The American Cancer Society publishes an excellent resource called Sexuality and Cancer. There is a version available for men and a version available for women. Call 1-800-227-2345 and tell them which version you want.
MSK has a Sexual Health Program to help patients address the impact of their disease and treatment on sexual health. You can meet with a specialist before, during, or after your treatment.
- Female Sexual Medicine and Women’s Health Program: call (646) 888-5076 for an appointment
- Male Sexual and Reproductive Medicine Program: call (646) 888-6024 for an appointment
The diagnosis and treatment of cancer can be a very stressful and overwhelming event. You may feel depressed, anxious, confused, afraid, or angry. You may have strong feelings about any permanent changes. These changes can have an impact on your emotional well-being. Help is available for you at any time. If you would like counseling, your nurse can give you a referral to see a social worker, psychiatrist, or counselor.
Also, you may find it comforting to speak with a cancer survivor or caregiver who has been through a similar treatment. Through our Patient-to-Patient Support Program, you have the chance to speak with former patients and caregivers. To learn more about this program, call (212) 639-5980.
Call Your Doctor or Nurse if You Have:
- A temperature of 100.4° F (38° C) or higher
- Nausea, vomiting, or both so severe that you cannot keep anything you eat or drink (or take through your feeding tube) down for 24 hours
- Constipation not relieved by medication
- Pain not relieved by your medication
- Blisters on your skin in the area being treated
After You Complete Treatment
Please be sure to keep your follow-up appointments with your radiation oncologist. He or she will evaluate your response to treatment. You may have blood tests, x-rays, and scans during these visits. Before coming, write down your questions and concerns. Bring this and a list of all your medications. If you are running low on any medication you need, let your doctor know before you run out. You can also call your doctor or nurse at any time after your treatment is completed, or in between follow-up visits, if you have any questions or concerns.
It is important to continue to take good care of yourself even after your treatment is finished. Here are a few key things to remember:
- Side effects of treatment will slowly go away over 4 to 8 weeks after your treatment is completed. Some side effects may take longer to go away. Continue to follow the suggestions described in this resource for any symptoms you experience after treatment is completed.
- Continue to take special care of your mouth for the rest of your life.
- Have regular dental follow-up appointments. See your dentist if your denture or appliance is not fitting well.
- If you must have any teeth pulled, this should be done by a dentist with experience in treating patients who have had radiation therapy to the head and neck. Call your radiation oncologist for a referral if you need one.
- Continue to use the fluoride toothpaste prescribed by your dentist.
- Avoid sweet, sticky foods. They can increase your risk of developing cavities.
- Maintain a healthy, well-balanced diet and take a daily multivitamin.
- If at the end of treatment you are using a feeding tube, follow-up with your gastroenterologist.
- If at the end of treatment you are eating a modified diet because of difficulty swallowing, ask your swallowing specialist how to gradually resume your usual diet.
- If at the end of treatment you are not able to maintain or gain weight, ask your dietitian how to increase your intake of protein and calories.
- If at the end of treatment you are taking pain medication, ask your nurse for instructions on how to gradually reduce the dose.
- Avoid tanning or burning your skin for the rest of your life. Use a PABA-free sunblock with an SPF of 30 or higher. Wear clothing that covers the skin that was treated with radiation.
- Avoid alcohol and tobacco. Drinking and smoking can increase your risk of developing a second cancer. They will also increase the dryness in your mouth.
The MSK Resources for Life After Cancer (RLAC) Program provides support services after your treatment is finished. To learn more about these services, call (646) 888-8106 or go to: www.mskcc.org/cancer-care/survivorship/services-survivors.