## 4 Discussion
The naive judge group rated the intelligibility of TE speakers to be significantly better than the electrolarynx speakers but found no significant difference in esophageal speakers. This may suggest that the phonetic construction of stimuli used for such assessments of postlaryngectomy speech must be carefully considered as an influencing factor in the accuracy scores obtained and how they may be weighed when comparing across studies. [PERSON] and colleagues have reported that when compared to traditional esophageal speakers, the consonant accuracy of TE speakers was significantly better [10]. Further, [PERSON] et al. attributed the superior accuracy of the TE speakers to differences in the aerodynamic driving sources between the two alaryngeal modes. Their study assessed three esophageal speakers, three TE speakers, and one dual-mode speaker who was proficient in both esophageal and TE modes. Nonsense stimuli (consonant-vowel-consonant) were presented to naive listeners who were asked to transcribe their responses using an open-set response paradigm. Plosives, fricatives, nasals, and liquid-glides produced by TE speakers were found to be significantly more intelligible when compared to stimuli produced by esophageal speakers; this finding was also consistent for the productions of the dual-mode speaker. While both speaker groups were similarly intelligible for voicing distinctions, the error pattern was different. Esophageal speakers were found to be better at producing voiceless targets; the production of voiced targets was found to be superior for the TE speakers; however, it is important to reiterate that these data were based on judgments of nonsense stimuli. We would, however, also like to acknowledge that the present data were collected in an optimal listening environment. Thus, the issue of reductions in the accuracy of consonant identification in less-than-ideal listening circumstances also must be considered. For this reason, the accuracy of identification will be influenced by not only the amount of background competition to the TE speech signal, but also by the type of noise [15]. [PERSON] et al. [18] assessed the speech acceptability and intelligibility of 15 TE speakers. Conversational speech, automatic speech, a standard passage, and the CRT were recorded on video tape. The listeners had no auditory training or clinical experience with alaryngeal speech. These listeners rated the TE speakers to be highly acceptable and intelligible with scores ranging from 80.7% to 97.5% and a mean score of 93%. These early results indicated that TE speakers are highly intelligible even to naive listeners. However, based on the findings from our study, whole-word scoring and the use of multiple-choice word lists may have inflated the scores in [PERSON] et al. [18] to some extent due to lexical, semantic, or other selection-based or listener-based factors [38; 39; 40; 41]. As noted, multiple-choice test materials may be influenced by both the number of foils provided within a response set and the phonetic composition of those foils. That is, foils that more closely align with the target, for example, differing in only a single, distinctive feature, may offer either greater or lesser perceptual challenges to the listener. From a clinical perspective, the use of a closed-set response format may pose inherent perceptual limitations. A listener also may identify a target word by chance alone based on a \"best guess\" approach from the options provided. Whole-word scoring methods were used in these past studies. This means that the response was scored either correct or incorrect with no special consideration of the specific nature of the errors. We believe that the identification of these errors via phonemic scoring can provide valuable information to the clinician about the speech production difficulties encountered by this clinical population. Minimally, we believe that our data support the notion that the content of specific word lists must be carefully considered in relation to the accuracy of outcomes generated.