## 5 Discussion  
This study identified relationships between OS and LC for TE speakers and two specific objectives were explored. First, we determined the association between listener judgments of two auditory-perceptual dimensions, overall severity (OS) and listener comfort (LC). These dimensions were assessed by 51 naive listeners for voice samples provided by 20 postlaryngectomy TE speakers. Second, we explored the utility of temporal and spectral acoustic models as correlates to the auditory-perceptual data. Thus, this study sought to address the auditory-perceptual evaluation of TE speech for two dimensions--OS and LC--as well as explore acoustic models to further quantify the TE samples studied. Our desire was to integrate and explain larger potential relationships between psychophysical assessments of TE voice by listeners and the acoustic characteristics of those speaker samples. Based on the data obtained, OS and LC are highly correlated. While the definitional boundaries of both OS and LC as provided in this study may overlap to some degree, strict definitions of both dimensions suggest a logical relationship between the two. That is, as judgments of severity related to the voice quality of TE speakers become poorer, listeners also indicate that they become less favorable in their desire to interact with those speakers (based on their voice quality). This finding suggests that listeners may become increasingly uncomfortable as a speaker's voice quality becomes less normal. While this is not unexpected, we would suggest that the social penalty is strongly associated with the perceived degree of voice abnormality exhibited by a non-normal speaker. These collective data suggest that acoustic assessments which are based on predictive models may provide valuable information in understanding the potential relationship between a TE speaker and how a listener judges such a sample. This is of particular interest with samples that may be judged as grossly abnormal related to the normal voice, those that are characterized by substantial and variable levels of noise (i.e., frequency and/or intensity perturbation), or in situations where the signal-to-noise ratio is degraded. Figure 3: The distribution of correlation coefficients for individual listeners indicates a wide range of listener-to-listener variability between the two dimensions of OS and LC. The dashed red line shows the threshold for a significant correlation. Although the present data are very specifically tied to postlarynectomy speakers who had undergone TE voice restoration, it is possible that similar findings could be found with other clinical voice populations. However, while we would anticipate that the transition of these data to other classes of disordered voice may be similar in other voice disordered groups (e.g., those with a dysarthris), one would carefully need to consider the potential influence of other speech or voice factors (e.g., changes in speech rate, articulatory precision, etc.) on judgments of both OS and LC. Therefore, regardless of the underlying cause or class of a voice disorder, changes in one's overall voice quality and its level of perceived severity relative to normal expectation [25] would likely create reduced levels of listener comfort during communication exchanges and this would include considerations of speaker gender [12; 28; 30; 31]. Finally, it is equally clear that other acoustic models beyond those presently employed, or variations thereof, may provide unique solutions to understanding how a listener perceives and quantifies the TE voice, regardless of the auditory-perceptual dimension(s) under evaluation. The potential relationship between OS and LC as derived from this empirical project suggests that as voice quality becomes more deviant and, hence, more severely disordered relative to normal expectations, a social penalty will also emerge.