## 4 Discussion
### Limitations of the Present Study  
Several limitations associated with the present work deserve mention. First, the present study used only a small sample of TE speakers, all of which were judged to be proficient speakers by experienced clinicians. For this reason, these results cannot be generalized to less proficient speakers, or those of similarly high levels of speech proficiency. Further, despite being naive listeners, it is possible the listener bias existed to some extent due to their experience with IPA. Based on our observation of variability in accuracy scores both across speakers and listeners may suggest that the more refined phoneme scoring may offer value for ongoing clinical assessments of TE speakers. However, the time demand associated with phonemic transcription may offer limits from a clinical standpoint. Furthermore, list construction remains a question relative to other sources of variability and in the present study, the ability to generalize findings across word lists is difficult due to contextual issues (e.g., the variation in vowels used across stimulus lists). That is, accuracy scores will be influenced by the content of stimuli within any given word list. In this regard, the W&B materials provided reduced accuracy scores; however, the stimuli included in that list had a greater representation of consonants than the other two stimulus lists studied. Ultimately, we believe that the ability to evaluate the widest array of consonants will potentially provide a more beneficial means of assessment for clinical use. Yet it should be mentioned that, despite many years of information on postlaryngectomy speech accuracy, no standard method has yet emerged [45; 54]. We would, however, also like to note that potential learning effects relative to the stimuli presented cannot be ruled out in relation to listener responses. We did attempt to mitigate this concern by carefully instructing listeners to transcribe exactly what they heard [53], rather than guessing based on exposure to other samples. While this approach cannot fully rule out learning, on debriefing listeners once they completed the task, all indicated that they were diligent in seeking to provide transcriptions of what they heard. The final issue relates to the participant speakers and the scores obtained. As noted, these five speakers were judged by experienced clinicians to be highly proficient. Overall, and regardless of the word list assessed, the present data support these speakers' excellent levels of TE speech proficiency. However, the construction of word list stimuli appears to be an important variable in accuracy that cannot be disregarded. This finding was consistently observed for all speakers except for Speaker D who was perceived as more intelligible for initial consonants on the W&B list than for those of the CRT. Initial consonant production was similar for the NIT and for the CRT for both overall scores and individual speaker scores. This might suggest that as overall subjective judgments of speaker proficiency decreases, we might observe a commensurate increase in productive/perceptual errors during more refined assessments of speech accuracy. Thus, the types of errors noted (i.e., manner of production, place, voicing, phonetic position in stimulus) may not necessarily be demonstrated in a consistent manner to that observed for our speakers. We would, however, anticipate that less proficient speakers would also present with greater levels of challenge across consonant categories. That is, phonemic errors are likely to be very individualized and idiosyncratic in nature which may result in complex types of errors that reflect deficits across multiple distinctive features that characterize any given word list [46]. Further, the influence of noise on listener judgments must always be considered in the larger context of speech accuracy and intelligibility [15]. This suggestion would argue for efforts to standardize speech intelligibility assessment tools to document reductions in postlaryngectomy speech accuracy.