## 4 Discussion  
This study was designed to evaluate the potential influence of scoring method and stimulus list construction on the accuracy of a small group of highly proficient TE speakers. Based on the present data, care must be taken in comparing speech sound accuracy when stimulus lists differ across assessments. Further, more sensitive methods of scoring at the phonemic level appear to provide a critical component of valid speech accuracy assessments. Similar to previous research related to the dysartharias, acoustic characteristics of target stimuli will also provide the foundation from which speech accuracy can be more comprehensively compared; this is also true for alaryngeal voice methods, such as both TE and esophageal speech [5, 6, 7, 8, 9, 43]. Because the TE voicing mechanism is driven by pulmonary air, aerodynamic considerations are essential to our understanding of speech sound production in these speakers [27, 28, 29, 30, 31, 32]. Thus, our findings provide a framework from which further understanding of speech accuracy, and ultimately intelligibility, can be evaluated in assessments of alaryngeal speakers in general and for TE speakers specifically. Perhaps one of the most noteworthy findings from the current work is the variability that was observed between speakers given their generally good levels of communication effectiveness as subjectively assessed by experienced clinicians. Despite rating each of these speakers as excellent in the context of a running speech sample, whole-word and consonant specific intelligibly between these individuals was highly variable. The current findings may support the use of clinical assessment in both quiet and noisy environments to adequately identify speaker-specific challenges across such varied communication contexts [15]. If some consonants are more likely to be misperceived in quiet, it is not unreasonable to assume that further breakdown in accuracy will occur in the presence of noise. Furthermore, the use of phoneme-specific analysis is encouraged to identify individual challenges associated with manner of articulation. Yet it is also important to acknowledge that the anticipation of some types of errors, most notably those associated with voicing, are common in TE speakers. If the composition of any given stimulus list is not considered, comparison and monitoring of a TE speaker's accuracy may be limited [53]. Finally, as has been suggested in prior research, concerns specific to both the phonetic complexity of the target stimuli, lexical or semantic factors [40], as well as their relative word frequency, may also influence the accuracy scores obtained [36, 37, 48]. Although all postlaryngectomy alaryngeal speakers will exhibit voicing errors regardless of alaryngeal mode, TE speakers may exhibit unique patterns. For example, TE speakers appear to exhibit a distinct \"voicing advantage\" over esophageal speakers [10] despite use of a non-adductor/abductor postlaryngectomy voice mechanism. Despite these findings, few studies have considered or investigated TE speaker performance relative to a specific intelligibility word list. Ultimately, the concern raised in this context relates to the potential for any given word list to vary in the accuracy score that is derived. While it is understood that measures reflecting mean group accuracy scores may not be representative of individual speaker performance, we are more concerned with potential variability that is a direct consequence of list construction. Most notably, Speaker C was consistently perceived as the most intelligible speaker for all three intelligibility word lists studied. Further, Speakers C and D serve as cases in point to the observed variability across lists (see Table 1), yet other considerations may be noted. For example, intelligibility outcomes for three laryngectomee groups were studied by [PERSON] and [PERSON] [19] and expert judges rated TE speakers to be significantly better than the esophageal and electrolarynx speakers on measure of intelligibility.