## 4 Discussion
### Implications of Data  
With effective speech rehabilitation, a laryngectomized patient can achieve generally good levels of TE speech intelligibility. This study demonstrated that individual speaker variability, however, must be considered through the implementation of phonemic scoring of any given speaker's productions. That is, the identification of individualized patterns of production/perception may be optimized through use of distinctive features, most specifically relative to voicing and manner of production, as a point of assessment. Thus,accuracy scores will be stimulus dependent due to unique aerodynamic and acoustic characteristics of the TE signal [9; 10; 27; 28; 29; 30; 31; 33; 34]. This more refined method of analysis will certainly be a reflection of how any given stimulus word list is constructed. In the present study, the W&B stimulus word list had the lowest variability of the three lists compared in this study, suggesting that it may be a more useful tool for determining the accuracy of TE speakers. Thus, a clinician may have greater confidence that changes in a speaker's speech production (and consequently their perceived accuracy) during the period of therapy are due to treatment rather than being a function of variation in phonemic representation that characterizes any specific word list. Thorough analysis of a speaker's phonemic productions is an important and sensitive procedure which should precede initial speech therapy in order to determine baseline performance. We would, however, note that phonemic scoring is not errorproof, particularly when real word stimuli are used as listener identification of target stimuli can be influenced by word frequency, familiarity, etc. [48]. The findings of the present study warrant further research into TE speech accuracy and the construction of stimuli used to assess intelligibility. More investigation into individual speaker differences would provide better information for clinical assessment and therapy prognosis. Additionally, concerns about the experience of the listeners who provide judgments must always be considered [54]. One of the restrictions of the small speaker sample used in the present study is the reduced generalizability of the findings to a larger TE speaker population. By investigating a larger sample, using a wider range of TE speakers, more generalizable results about the use of phonemic scoring and the W&B list and potentially other measures for accuracy evaluation may be obtained. Investigation into the test-retest reliability of the intelligibility assessment suggested in the present study could provide relevant information for clinical management. Finally, investigation into the pattern of production errors a speaker makes could provide greater information which would be of clinical utility in the treatment of TE speakers, thereby improving the prognosis of speech rehabilitation. The final area of discussion that has practical implications relates to the surgical variability of those who undergo total laryngectomy and may pursue TE puncture voice restoration as a rehabilitation option. The speakers present in the study had undergone standard laryngectomy without reconstruction; for that reason, the present data and the generalization of our findings to those with more extensive surgical resections and/or reconstruction must be carried out with caution. Of particular importance in this regard is the potential loss of valuable speech production information should whole-word and/or forced choice judgment paradigms be employed; clearly our data suggest that information may be lost using such methods. However, the present findings should encourage future awareness specific to the phonetic structure of stimuli used for testing postlaryngectomy speech accuracy [10; 33; 34; 52; 53]. At the very least, comparison across postlaryngectomy TE speaker groups (i.e., those with reconstruction and those without) may be undertaken.