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Medical Terminology > Chapter 15 > Flashcards

Chapter 15 Flashcards

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USMLE® Step 1 flashcards
1
Q

Ears, nose and throat

A

Interrelated group of anatomic structures of the ears, most, and throat, located in the head and neck, that are considered together for medical specialty of otolaryngology.

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2
Q

Auricle

A

The visible external ear. Also known as the pinna

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3
Q

Cerumen

A

Waxy, sticky substance secreted by glands in the external auditory canal. It traps dirt and has an antibiotic action against microorganism.

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4
Q

External auditory canal

A

Passageway from the external ear to the tympanic membrane. It contains glands that secrete cerumen. The external auditory meatus is the opening to the external auditory canal.

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5
Q

External ear

A

First part of the ear. It consists of the visible external structures of the auricle (pinna), helix, tragus, external auditory meatus, external auditory canal, and the bony mastoid process behind the ear.
The external ear also includes the tympanic membrane at the end of the external auditory canal.

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6
Q

Helix

A

Outer rim of tissue and cartilage that forms the C shape of the external ear and ends at the earlobe.

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7
Q

Mastoid process

A

Bony projection of the temporal bone behind the external ear. It contains air cells that connect to the middle ear and to the Eustachian tube.

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8
Q

Tragus

A

Triangular cartilage anterior to the external auditory meatus.

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9
Q

Tympanic membrane

A

Thin, pearly gray membrane at the end of the external auditory canal. It divides the external ear from the middle ear. Also known as the eardrum.

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10
Q

Eustachian tube

A

Tube that connects the middle ear to the nasopharynx to allow air pressure in the middle ear and mastoid air cells to equalized with air pressure in the nose, throat, and outside of the body.

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11
Q

Incus

A

Second bone of the middle ear. It is connected to the malleus on one end and to the stapes on the other end. Also known as the anvil because of its shape.

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12
Q

Malleus

A

First bone of the middle ear. It is connected to the tympanic membrane on one end and to the incus on the other end. Also known as the hammer because of its shape.

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13
Q

Middle ear

A

Second part of the ear. It is a cavity (hollow area) in the temporal bone that contains the malleus, incus, and stapes bones. The middle ear is connected to the air cells of the mastoid process and to the nasopharynx by the Eustachian tube.

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14
Q

Ossicles

A

The three tiny bones of the middle ear: malleus, incus and stapes. These bones are connected to each other to form the ossicular chain.

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15
Q

Stapes

A

Third bone of the middle ear. It is connected to the incus on one end and fits into the membrane-covered opening of the oval window on the other end. Also known as the stirrup because of its shape.

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16
Q

Cochlea

A

Spiral-shaped structure that sends sensory information to the brain about sound waves that enter the ear.

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17
Q

Inner ear

A

Third part of the ear. It is a cavity that contains the vestibule, semicircular canals, and cochlea, as well as the oval window and round window in the temporal bone between the middle and inner ear.

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18
Q

Labyrinth

A

All of the structures of the inner ear

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19
Q

Oval window

A

Small, membrane-covered opening in the temporal bone between the middle ear and inner ear. It is connected to the stapes of the middle ear.

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20
Q

Round window

A

Small, membrane-covered opening in the temporal bone between the middle ear and inner ear

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21
Q

Semicircular Canals

A

Three separate but intertwined fluid-filled canals in the inner ear that are each oriented in a different plane (horizontally, vertically, and obliquely). They send sensory information to the brain about the position of the head.

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22
Q

Vestibule

A

Fluid-filled structure at the entrance to the inner ear. The superior part of the vestibule becomes the semicircular canals, and the inferior part becomes the cochlea.
The vestibules has two small, membrane-covered openings in its bony wall: The oval window and round window.

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23
Q

Ala

A

Flared cartilage on the side of the nostril

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24
Q

Mucosa

A

Mucous membrane lining in the nasal cavity. It covers the turbinates and produces mucus that gives warmth and moisture to the air and traps foreign particles.

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25
Q

Naris

A

A nostril, one of the two external openings into the nasal cavity

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26
Q

Nasal cavity

A

Hollow area inside the nose whose walls are formed by the ethmoid and maxillary bones. It is lined with mucosa and is divided in the middle by the nasal septum. It contains the turbinates.

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27
Q

Nasal dorsum

A

Vertical ridge in the middle of the external nose. It is supported by the nasal bone.

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28
Q

Nasal septum

A

Vertical wall of cartilage and bone that divides the nasal cavity into right and left sides.

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29
Q

Turbinates

A

Three long, scroll-like projections of bone (superior, middle, and inferior turbinates) that jut into the nasal cavity to slow down inhaled air. Also known as the nasal conchae. The turbinates are covered with mucosa.

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30
Q

Ethmoid sinuses

A

Groups of small air cells within the ethmoid bone, located between the nose and the eyes.

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31
Q

Frontal sinuses

A

Hollow, air-filled cavities in the frontal bone, just superior and medial to each eyebrow.

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32
Q

Maxillary sinuses

A

Hollow, air-filled cavities in the maxilla (upper jaw bone) on either side of the nose. The maxillary sinuses are the largest of the sinuses.

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33
Q

Sinus

A

Hollow, air-filled cavity in a facial or cranial bone. A sinus is lined with mucous membrane that produces mucus.
There are four pairs of sinuses (frontal, maxillary, ethmoid, and sphenoid). They are connected to each other and to the nasal cavity.
Together, they are the paranasal sinuses.

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34
Q

Hard palate

A

Structure that divides the oral cavity from the nasal cavity. It consists of the maxilla, palatine, and vomer bones. Together with the soft palate, it forms the roof of the mouth.

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35
Q

Mentum

A

The chin. The anterior part of the mandible (lower jaw)

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36
Q

Mucosa

A

Mucous membrane that produces mucus. The oral mucosa lines the oral cavity. The buccaneers mucosa lines the cheek area of the oral cavity.

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37
Q

nasolabial fold

A

Skin crease from the nose to the lip at the corner of the mouth.

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38
Q

Oral cavity

A

Hollow area inside the mouth that contains the tongue, hard palate, soft palate, uvula, teeth, and gums. It is lined with oral mucosa.
In the cheek area, this is Buffalo mucosa.
The hard and soft palate form the roof of the mouth. The mandible forms the floor of the mouth.

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39
Q

Philtrum

A

Vertical groove in the skin of the upper lip

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40
Q

Soft palate

A

Soft tissue extension of the hard palate at the back of the oral cavity. It ends with the fleshy uvula that hangs down in the back of the oral cavity.

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41
Q

Submental lymph nodes

A

Lymph nodes beneath the chin. They contain special cells that are active in the immune response and attack bacteria and viruses in the oral cavity.

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42
Q

Temporomandibular joint (TMJ)

A

Movable joint where each side of the mandible (lower jaw) is attached to the temporal bone of the cranium

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43
Q

Tongue

A

Large muscle in the oral cavity, the base of which is attached to the mandible

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44
Q

Adenoids

A

Lymphoid tissue located in the roof and walls of the nasopharynx. The adenoids are part of the lymphatic system and function in the body’s immune response.

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45
Q

Laryngopharynx

A

Area of the throat that is posterior to the larynx. It contains the lymphoid tissue of the lingual tonsils.

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46
Q

Lingual tonsils

A

Lymphoid tissue located on either side of the base of the tongue in the laryngopharynx. The tonsils are part of the lymphatic system and function in the body’s immune response.

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47
Q

Nasopharynx

A

Area of the throat that is posterior to the nasal cavity. The nasopharynx contains the lymphoid tissue of the adenoids and is connected to the middle ear by the Eustachian tube.

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48
Q

Oropharynx

A

Area of the throat that is posterior to the oral cavity. It contains the lymphoid tissue of the palatine tonsils.

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49
Q

Palatine tonsils

A

Lymphoid tissue located on either side of the soft palate in the oropharynx. The tonsils are part of the lymphatic system and function in the body’s immune response.

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50
Q

Pharynx

A

The throat. It is a shared passageway for food and air and is divided into three area: The nasopharynx, oropharynx, and laryngopharynx.
It contains lymphoid tissues of the adenoids and lingual and palatine tonsils.

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51
Q

Epiglottis

A

Lid-like structure that seals the larynx during swallowing.

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52
Q

Glottis

A

V-shaped structure in the larynx. It contains cartilage, ligaments, and the vocal cords.

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53
Q

Larynx

A

Short, triangular structure that is visible on the anterior surface of the neck as the laryngeal prominence (Adam’s apple). Internally, it contains the epiglottis, glottis, and vocal cords. Also known a the voice box.

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54
Q

Vocal cords

A

Bands of connective tissue in the glottis that vibrate to produce sounds during speaking and singing

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55
Q

Auditory cortex

A

Structure in each temporal lobe of the brain that interprets nerve impulses from the cochlea fro the sense of hearing.

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56
Q

Cochlea

A

Hair cells (sensory receptors) in the cochlea detect vibrations from the fluid in the vestibule as loudness (intensity) and pitch (frequency) and change them into nerve impulses that travel on the cochlear branch of the vestibulocochlear nerve.

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57
Q

External auditory canal

A

Carries sound waves from the external ear to the tympanic membrane

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58
Q

External ear

A

Captures sound waves and funnels them into the external auditory canal where the sound waves are converted into the vibrations of the tympanic membrane.

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59
Q

Inner ear

A

The vibration of the stapes becomes vibrations of the membrane-covered oval window and the fluid in the vestibule of the inner ear. These vibrations are transmitted to the cochlea of the inner ear

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60
Q

Middle ear

A

Malleus, incus, and stapes bones of the middle ear move in response to vibrations of the tympanic membrane. The stapes transmits these vibrations to the membrane-covered oval window between the middle and inner ear.

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61
Q

Oval window

A

Small, membrane-covered opening in the temporal bone between the middle and inner ear. it is connected to the stapes in the middle ear, and the stapes transmits its vibrations to the membrane of the oval window, which transmits vibrations to the fluid in the vestibule.

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62
Q

Round window

A

Membrane-covered opening in the temporal bone that divides the middle ear from the inner ear.
The round window acts as a “saftey valve,” allowing vibrations in the vestibule to decrease as they cause the membrane to bulge into the middle ear.

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63
Q

Tympanic membrane

A

Changes sound waves into vibrations that cause movement of the bones of the middle ear.

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64
Q

Vestibulocochlear nerve

A

Cranial nerve VIII. Carries nerve impulses from the cochlea (via the cochlear branch) for the sense of hearing. Carries nerve impulses from the semicircular canals (via the vestibular branch) to maintain balance.

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65
Q

Olfaction

A

The sense of smell. Receptors in the nose detect the molecules in odors and relay this information via the olfactory nerve (cranial nerve I) to the olfactory cortex in the brain where the smell is identified.

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66
Q

Balance

A

Includes maintaining body postition and initiating movement.
Balance is based on combined sensory information from the semicircular canals of the inner ear, visual information from the eyes, and sensory information from the nerves and muscles about the position of the body.

67
Q

Proprioception

A

Awareness of the position of all parts of the body.

68
Q

Semicircular canals

A

Canals in the inner ear that are oriented in three different planes. They contain hair cells that send sensory information to the brain about the position of the head and neck

69
Q

Vestibular branch

A

Part of the vestibulocochlear nerve that carries nerve impulses from the semicircular canals to the brainstem and then to the cerebellum of the Braun to maintain balance.

70
Q

EAC

A

External auditory canal

71
Q

ENT

A

Ears, nose, and throat

72
Q

T-MOBILE

A

Tympanic membrane

73
Q

TMJ

A

Temporomandibular joint

74
Q

Acoustic neuroma

A

Benign tumor of the vestibulocochlear nerve.

Depending on the location of the tumor, it can cause pain, dizziness, or hearing loss.

75
Q

Cerumen impact ion

A

Cerumen (earwax), epithelial cells, and hairs form a mass that concludes the external auditory canal.

76
Q

Cholesteatoma

A

Benign, slow-growing tumor in the middle ear. It contains cholesterol deposits and epithelial cells. It can eventually destroy the bones of the middle ear and extend into the air cells of the mastoid process. The underlying cause is usually chronic otitis media.

77
Q

Hearing loss

A

Temporary or progressive, permanent decline in the ability to hear sounds in one or both ears. Patients with a hearing loss are said to be hearing impaired or hard of hearing.

78
Q

Conductive hearing loss

A

occurs when sound eaves cannot reach the inner ear because of a foreign body or infection in the external auditory canal, perforation of the tympanic membrane, fluid behind the tympanic membrane, degeneration of the bones in the middle ear, or otosclerosis.

79
Q

Sensorineural hearing loss

A

Occurs due to disease of the cochlea, damage to the inner ear from excessive noise, or changes due to aging that hinder the production or transmission of nerve impulses by the vestibulocochlear nerve.

80
Q

mixed hearing loss

A

A combination of both conductive and sensorineural hearing loss.

81
Q

Low-frequency hearing loss

A

The inability to hear low-pitched sounds

82
Q

High-frequency hearing loss

A

The inability to hear high-pitched sounds

83
Q

Prebycusis

A

Bilateral hearing loss due to aging. Also known as presbyacusis.

84
Q

Anacusis

A

Total deafness. Deaf-mutism is total deafness coupled its the inability to speak.

85
Q

Hemotympanum

A

Blood in the middle ear that can be seen behind the tympanic membrane. It can be caused by a bacterial infection or trauma.

86
Q

Labyrinthitis

A

Bacterial or viral infection of all of the structures of the inner ear, causing hearing loss and vertigo

87
Q

mastoiditis

A

Bacterial infection of the air cells in the bone of the mastoid process.
This is caused by an untreated or chronic infection in the middle ear (otitis media).
Symptoms include swelling and tenderness of the mastoid process behind the ear with drainage from the ear.

88
Q

Meniere disease

A

Edema or fluctuation pressure of the fluid in the inner ear, causing episodes of tinnitus, vertigo, hearing loss, and a feeling of fullness in the ear. It often affects just one ear.

89
Q

Motion sickness

A

Dizziness, nausea and vomiting, and a headache that is brought on by the irregular motions of riding in a car, boat, or airplane.

90
Q

Otitis externa

A

Bacterial infection of the external auditory canal.
There is throbbing earache pain with a swollen, re external auditory canal and serous (clear) or purulent (with pus) drainage. it is caused by a foreign body in the ear or by the patient scratching or probing inside the ear.

91
Q

Otitis media

A

Acute or chronic bacterial infection of the middle ear that also affects the tympanic membrane of the external ear.
There is myringitis (redness and inflammation of the tympanic membrane), otalgia, a feeling of pressure, and bulging of the tympanic membrane.
There can be an effusion that creates an air-fluid level. This fluid can be serous (clear) or suppurative (with pus).

92
Q

Otorrhea

A

Drainage of serous or purulent fluid from the ear. It can be caused by otitis externa or otitis media (when the tympanic membrane ruptures).
It can also be caused by a fracture of the temporal bone of the cranium with leakage of cerebrospinal fluid into the ear.

93
Q

Otosclerosis

A

Abnormal deposits of bone in the middle ear, particularly between the stapes and the oval windows. The stapes becomes immovable, causing conductive hearing loss. Certain families have a genetic predisposition to developing otosclerosis.

94
Q

Ruptured tympanic membrane

A

Tear in the tympanic membrane due to excessive pressure or a middle ear infection.
In pilots and deep-sea divers, unequal air pressure in the middle ear compared to the surrounding air or water pressure can rupture the tympanic membrane

95
Q

Tinnitus

A

Sounds (such as buzzing, ringing, hissing, or roaring) that are heard constantly or intermittently in one or both ears, especially in a quiet environment.

96
Q

Vertigo

A

Sensation of motion and spinning when the head and inner ear move but the body is not moving, with a feeling that one’s body or the environment is spinning or rotating.

97
Q

Allergic rhinitis

A

Allergic symptoms in the nose. in response to an inhaled antigen, basophils and mast cells of the immune system release histamine.
This causes nasal stuffiness; sneezing; rhinorrhea of the turbinates in the nose with their red, edema toes, and swollen mucous membranes; and post nasal drip (PND)

98
Q

Anosmia

A

Temporary or permanent loss of the sense of smell. It is most often caused by head trauma

99
Q

Epitaxis

A

Sudden, sometimes severe bleeding from the nose. It is due to irritation or dryness of the nasal mucosa with rupture of a small artery or it can be caused by trauma to the nose.

100
Q

Nasal polyp

A

Benign, soft growth of the mucous membrane in the nose or sinuses. A single polyp may grow large enough to limit the flow of air or there may be several polyps.

101
Q

Rhinophyma

A

Redness and hypertrophy (enlargement) of the nose with small-to-large, irregular lumps, usually seen in men. It is caused by the increased number of sebaceous glands associated with rosacea of the skin.

102
Q

Septal deviation

A

Lateral displacement of the nasal septum, significantly narrowing one nasal airway.
This can be a congenital condition or it can be caused by trauma to the nose.

103
Q

Sinusitis

A

Acute or chronic bacterial infection in one or more of the sinus cavities. There is headache, pain in the forehead or cheekbones over the sinus, post nasal drainage, fatigue, and fever.

104
Q

Upper respiratory infection

A

Bacterial or viral infection of the nose that can spread to the throat and ears. The nose is also a part of the respiratory system, and this is an upper respiratory infection.
Also known as a common cold or head cold.

105
Q

Cancer of the mouth and neck

A

Malignant tumor of the mucous membrane in the oral cavity, pharynx, or larynx. Smoking and using smokeless chewing tobacco can cause this.

106
Q

Cleft lip and palate

A

Congenital deformity in which the skin of the lip or the bones of the right and left maxilla fail to join in the center before birth.
The resulting cleft can affect the nose, lip, teeth and gums, and hard and soft palate, and the cleft can be unilateral or bilateral.

107
Q

Cold sores

A

Recurring, painful clusters of blisters on the skin of the lips or nose.
They are caused by infection with herpes simplex virus type 1.
After the initial infection, the virus remains dormant in a nerve until trigger of stress, sunlight, illness, or menstruation cause it to reappear. Also known as fever blisters.

108
Q

Glossitis

A

Infection or inflammation of the tongue. It is caused by irritation from spicy or hot food, a food allergy, an infection, or vitamin B deficiency.

109
Q

Leukoplakia

A

Thickened, irregular white patches on the tongue and mucous membrane of the oral cavity. If it is caused by chronic irritation from tobacco use, it can become cancerous.

110
Q

Pharyngitis

A

Bacterial or viral infection of the throat.
When it is caused by the bacterium group A beta-hemolytic streptococcus.
Known as strep throat

111
Q

Temporomandibular joint (TMJ) syndrome

A

Dysfunction of the movement of the temporomandibular joint. There is clicking of the joint, pain, muscle spasm, and difficulty opening the jaw.
Caused by clenching or grinding the teeth (often during sleep) or by misalignment of the teeth.

112
Q

Thrush

A

Oral infection caused by the yeast Candida albicans. it coats the tongue and mucosa of the oral cavity.
Thrush is common in infants but is also seen in immunocompromised patients and patients with AIDS because their immune system cannot control the mouth, allowing overgrowth of Candida albicans.

113
Q

Tonsillitis

A

Acute or chronic viral or bacterial infection of the pharynx and palatine tonsils.
There is a sore throat and difficulty swallowing, with mouth breathing and snoring. The tonsils hypertrophy and contain pus and debris. The adenoids may also hypertrophy and block the Eustachian tubes.

114
Q

Cervical Lymphadenopathy

A

ENlargement of the lymph nodes in the neck. It is caused by infection, cancer, or the spread of a cancerous tumor from another site.

115
Q

Laryngitis

A

Bacterial or viral infection in the larynx. This causes swelling and inflammation with hoarseness or complete loss of the voice, difficulty swallowing, and a cough.

116
Q

Vocal cord nodule

A

Small, benign, fibrous growth on the surface of a vocal cord. A vocal cord polyp is a larger, soft, benign growth of the mucous membranes that contains blood vessels.

117
Q

Audiometry

A

Test the measures hearing acuity and documents hearing loss. The patient puts on headphones that are connected to an audiometer, which produces a series of pur tones, each at a different frequency (high or low pitch) and varying in intensity.

118
Q

Brainstem auditory evoked response (BAER)

A

Test that analyzes the brain’s response to sounds. The patient listens as an audiometer produces a series of clicks. Electoenchpalography (EEG) that records the brain waves is performed at the same time.

119
Q

Rinse and Weber hearing tests

A

The Rinne tuning fork test evaluates bone conduction versus air conduction of sound in one ear at a time. A vibrating tuning fork is placed against the mastoid process behind one ear to test the bone conduction of sound.

120
Q

Tympanometery

A

Test that measures the ability of the tympanic membrane and the bones of the middle ear to move. Air pressure is used to the external auditory canal.

121
Q

Culture and sensitivity (C&S)

A

Laboratory test to identify which bacterium is causing an ENT infection.
A specimen of mucus or pus from the patient’s nose, external ear, adenoids, tonsils, or throat is placed in a culture dish with disks of antibiotic drugs to see which drug the bacterium is sensitive to; this will be the antibiotic drug that is prescribed.

122
Q

Rapid strep test

A

Test kit for strep throat.

A swab of mucus from the patient’s throat is missed with a solution of antibodies to group A streptococcus.

123
Q

RAST

A

Blood test that measures the amount of IgE produced when the blood is missed with a specific antigen.

124
Q

Sinus series

A

X-rays are taken from various angles to show all of the sinuses and confirm or rule out a diagnosis of sinusitis. Sinusitis shows as cloudy, opacified sinuses or thickened mucous membranes.

125
Q

Nose, sinus, mouth, and throat examinations

A

Procedures in which a nasal speculum is used to widen the nostril, while a penlight lights the nasal cavity.

126
Q

Otoscopy

A

Procedure to examine the external auditory canal and tympanic membrane.

127
Q

Romberg sign

A

Procedure to assess balance. The patient stands with the feet together and the eyes closed.

128
Q

Antibiotic drug

A

Treats bacterial infections of the ears, nose, sinuses, or throat.

129
Q

Decongestant drug

A

Constricts blood vessels and decreases swelling of the mucous membranes of the nose and sinuses caused by colds and allergies.

130
Q

drug used to treat motion sickness

A

Decreases the sensitivity of the inner ear to motion and keeps nerve impulses from the inner ear from reaching the vomiting center in the brain.

131
Q

Cheiloplasty

A

Procedure to repair the lip, usually because of a laceration.

132
Q

Cochlear implant

A

Procedure to insert a small, battery-powered implant beneath the skin behind the ear.

133
Q

Endoscopic sinus surgery

A

Procedure that uses an endoscope that is inserted through the nostril to examine the sinuses.

134
Q

Mastoid to my

A

Procedure to remove part of the mastoid process of the temporal bone because of infection.

135
Q

Myringotomy

A

Procedure that uses a myringotome to make an incision in the tympanic membrane to drain fluid from the middle ear.

136
Q

Otoplasty

A

procedure that uses plastic surgery to correct deformities of the external ear. When it corrects protruding ears, it is known as an ear pinning.

137
Q

Polypectomy

A

Procedure to remove polyps from the nasal cavity, sinuses, or vocal cords.

138
Q

Radical neck dissection

A

Procedure to treat extensive cancer of the mouth and neck.

Part of the jaw bone, tongue, lymph nodes, and muscles of the neck are removed.

139
Q

Rhinoplasty

A

Procedure that uses plastic surgery to change the size or shape of the nose

140
Q

Septoplasty

A

Procedure to correct a deviated septum.

141
Q

Stapedectomy

A

Procedure for otosclerosis to remove the diseased part of the stapes and replace it with a prosthetic device.

142
Q

Tonsillectomy and adenoidectomy (T&A)

A

Procedure to remove the tonsils and adenoids in a patient with chronic tonsillitis and hypertrophy of the tonsils and adenoids

143
Q

Tympanoplasty

A

Procedure to reconstruct a rupture tympanic membrane.

144
Q

ABR

A

Auditory brainstem response

145
Q

AD, A.D.

A

Right ear

146
Q

AS, A.S.

A

Left ear

147
Q

AU, A.U.

A

Both ears

148
Q

BAER

A

Brainstem auditory evoked response

149
Q

C&S

A

Culture and sensitivity

150
Q

Db

A

Decibel

151
Q

EAC

A

External auditory canal

152
Q

ENT

A

Ears, nose, and throat.

153
Q

HEENT

A

Head, eyes, ears, nose and throat

154
Q

Hz

A

Hertz

155
Q

PE

A

Pressure-equalizing (tube)

156
Q

PND

A

Post nasal drip

157
Q

RAST

A

Radio allegros orient test

158
Q

T&A

A

Tonsillectomy and adenoidectomy

159
Q

TM

A

Tympanic membrane

160
Q

TMJ

A

Temporomandibular joint

161
Q

URI

A

Upper respiratory infection

162
Q

Audiologist

A

Allied health professionals who perform hearing tests, diagnose hearing loss, and determine how patinets can best use their remaining hearing.

163
Q

Otolaryngologists or Otorhinolaryngologists

A

Physicians who practice in the medical specialty of otolaryngology.

Medical Terminology (15 decks)

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