Speech Intelligibility, Acceptability, and Communication-Related ...

ORIGINAL ARTICLE 

Speech Intelligibility, Acceptability, and 

Communication-Related Quality of Life 

in Chinese Alaryngeal Speakers 

Ida K.-Y. Law, MPhil; Estella P.-M. Ma, PhD; Edwin M.-L. Yiu, PhD 

Objective: To investigate (1) speech intelligibility and 

acceptability in using 4 different alaryngeal speech methods: 

esophageal (ES), electrolaryngeal (EL), pneumatic 

device (PD), and tracheosophageal (TE) speech; and 

(2) communication-related quality of life (QOL) in the 

alaryngeal speakers who used these 4 alaryngeal speech 

methods. 

Design: Survey. 

Participants: Alaryngeal speakers who had undergone 

speech rehabilitation and were recruited from the 

New Voice Club of Hong Kong. 

Main Outcome Measures: Speech samples collected 

from 49 alaryngeal speakers were rated by 6 judges for 

speech intelligibility and acceptability. The speakers also 

completed a communication-related QOL question- 

Author Affiliations: Voice 

Research Laboratory, Division of 

Speech and Hearing Sciences, 

and Centre for Communication 

Disorders, The University of 

Hong Kong, Hong Kong. 

TOTAL LARYNGECTOMY INvolves 

surgical removal of 

the whole larynx. 1 Following 

the surgical procedure, 

speech restoration 

can be achieved by different alaryngeal 

speech methods: electrolaryngeal (EL), 

pneumatic device (PD), esophageal (ES), 

and tracheosophageal (TE) speech. The 

speech production mechanisms of these 

alaryngeal speech methods are different. 

The EL, TE, and PD speech methods require 

separate devices for speech production; 

ES speech does not require external 

devices. 

Earlier studies 2-5 investigated speech intelligibility 

mostly of ES and EL speech. 

With the increasing popularity of TE and 

PD speech, more recent studies have been 

able to provide data on these 4 currently 

available speech methods. Although there 

was 1 study 6 that reported no significant difference 

in the speech intelligibility across 

naire called the Communication Activity and Participation 

After Laryngectomy. 

Results: We found that the ES and EL speakers showed 

considerably poorer speech intelligibility and communication-related 

QOL. The PD speakers demonstrated notably 

better speech intelligibility and acceptability ratings. 

However, high intelligibility and acceptability do 

not necessarily mean better QOL. The TE speakers, who 

demonstrated only the second highest speech intelligibility 

and acceptability, showed the best functional QOL. 

Conclusion: In speech rehabilitation after laryngectomy, 

QOL and speech intelligibility and acceptability 

should be considered together to find a balance that is 

acceptable to the patient. 

Arch Otolaryngol Head Neck Surg. 2009;135(7):704-711 

different alaryngeal speech methods, information 

to date generally shows that both 

TE speech 7,8 and PD speech 9 (which is more 

commonly used in Asian countries) show 

relatively good speech intelligibility. Alaryngeal 

speech intelligibility has also been 

found to be different across different age 

groups of listeners. 10 It has been shown that 

younger listeners are more proficient at understanding 

alaryngeal speech than older 

listeners. 10 Therefore, it is important to consider 

the age factor of the listeners in any 

alaryngeal speech intelligibility study. 

With its lexical tone feature, Chinese 

language adds another dimension to the 

study of alaryngeal speech intelligibility. 

Cantonese, a dialect of Chinese, is a tone 

language with 6 contrastive lexical tones, 

which means words that have the same 

sounds but only differ in pitch contour to 

signify different meanings. Cantonesespeaking 

alaryngeal speakers may face 

difficulties in producing various pitch 

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704 

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Table 1. Sex Distribution and Postoperation Time 

levels. Because pitch variations are essential to convey 

different lexical meanings of Cantonese words, such difficulties 

would affect speech intelligibility. A number of 

studies 11-14 of the Cantonese-speaking alaryngeal population 

focused on the speech intelligibility of different alaryngeal 

speech, with particular attention to lexical tone 

production. In the study by Yiu et al, 14 ES speakers demonstrated 

the highest speech intelligibility, but TE and 

PD speakers were more efficient in conveying lexical tones. 

Similarly, Ching et al 11 found that PD speakers showed 

the highest lexical tone intelligibility. A study by Ng et 

al 12 also found PD speakers to be able to produce better 

pitch variations, and hence better lexical tone production, 

than those using other types of alaryngeal speech 

methods, although there was no notable difference in the 

overall speech intelligibility among the 4 different alaryngeal 

speech types. 

Speech impairments following laryngectomy, including 

lower speech intelligibility and poorer lexical tone production, 

can have an impact on the alaryngeal speaker’s 

communication abilities. The extent to which speech intelligibility 

in different speech methods has an impact on 

quality of life (QOL) is largely unknown. Clements et al 15 

investigated ES, EL, and TE speakers’ satisfaction with their 

speech quality, communication abilities, interaction with 

others, and general QOL. They found TE speakers to be 

notably more satisfied with their speech method and to 

have better speech quality than ES and EL speakers. Nevertheless, 

no important difference was found in the level 

of satisfaction with QOL across the 3 alaryngeal speech 

groups. In general, their participants 15 reported low selfperceived 

ratings on their abilities to communicate over 

the telephone, high levels of limitation in communicating 

with others, and low levels of satisfaction with QOL. 

However, the small number of communication activities 

investigated in their study would not be adequate to assess 

the communication of the alaryngeal speaker population.Moreover,noPDspeakerswereincludedinthestudy 

because PD is not a commonly used speaking method in 

Western countries. 

In Hong Kong, most patients who have undergone laryngectomy 

are seen in public hospitals. The TE option 

is usually discussed with the patients before the surgery. 

Individuals who are not suitable for the TE option 

are all given the other 3 alaryngeal speech options. Most 

patients voluntarily choose the EL speech as their immediate 

means for communication after surgery. The other 

2 options, ES and PD, are also tried by patients during 

rehabilitation follow-up sessions. 

The present study compared the speech intelligibility 

and acceptability among 4 currently available alaryngeal 

Participants, No. Months After Laryngectomy, No. 

Alaryngeal Speech Mode 

Female Male Total Mean (SD) Range 

Esophageal 0 7 7 120.43 (51.23) 24-194 

Electrolarynx 0 14 14 62.79 (62.41) 6-190 

Tracheosophageal 1 12 13 70.92 (51.23) 20-181 

Pneumatic device 3 12 15 82.53 (60.44) 7-192 

speech modes, namely, EL, ES, TE, and PD speech using 

2 distinct age groups of listeners (25-33 years vs 60-65 

years). The study also compared the communicationrelated 

QOL among speakers of these 4 alaryngeal speech 

modes. The information on the speech intelligibility, acceptability, 

and QOL in different Chinese alaryngeal 

speech methods would provide health care workers and 

alaryngeal speakers an opportunity to make informed decisions 

as to the selection of a more suitable alaryngeal 

speech method. Although the PD method is not popular 

in Western societies, the information provided herein will 

serve to show that it can be a useful option for alaryngeal 

speakers whose mother tongue is one of those tonal 

languages. 

METHODS 

PARTICIPANTS 

Fifty-six native Cantonese-speaking alaryngeal speakers recruited 

from the New Voice Club of Hong Kong participated 

in the present study. All these participants had stopped attending 

the regular speech therapy clinics provided by the hospitals, 

and therefore it can be assumed that they all had achieved 

their maximum ability in acquiring the new speaking methods. 

Each participant was given a hearing screening test at octave 

frequencies ranging from 250 to 8 kHz at a 20-dB hearing 

level (HL). Seven participants were excluded from the study 

owing to other medication complications or having failed the 

hearing screening test. Therefore, only data from 49 alaryngeal 

speakers, ranging in age from 40 to 77 years (mean[SD] 

age, 65.37 [8.77] years) and with a postoperative period ranging 

from 6 to 194 months (mean [SD] duration, 79.22 [58.76] 

months) were included in the final analysis. Table 1 shows 

the sex distribution and postoperation time across the 4 alaryngeal 

speech method groups. All of the EL speakers used the 

neck-type EL devices, and all of the TE speakers were fitted with 

the Blom-Singer (InHealth Technologies, Carpinteria, California) 

valve using digital occlusion. The seemingly low proportion 

of female alaryngeal speakers indeed reflected the distribution 

of sex in the alaryngeal-speaking population in Hong 

Kong. Kruskal-Wallis 1-way analysis of variance (ANOVA) revealed 

no significant differences in the length of postoperation 

period (P=.27), age (P=.12), and education level (P=.20) 

among the 4 alaryngeal speech method groups. 

PROCEDURES 

Perceptual Evaluations of Speech 

Intelligibility and Acceptability 

Speech Material. The Cantonese Sentence Intelligibility Test 

(CSIT) 16 was used to assess the speech intelligibility of the par- 


705 



ticipants at sentence level. The CSIT was developed from the 

Assessment of Intelligibility of Dysarthric Speech (AIDS). 17 In 

the CSIT, 16 there are a total of 1100 daily Chinese (Cantonese) 

sentences (100 sentences, each with 5-15 words, for each sentence 

length set), which make up the master pool. These sentences 

do not contain quotations, reduplication, parentheses, 

proper names, or numbers larger than 10. For each speaker, a 

unique set of 22 sentences was randomly selected within the 

master pool, with a sentence length that varied from 5 to 15 

words. Two sentences were selected for each sentence length, 

and they were all printed out on a single sheet of A4 paper 

(2129-cm) in a 22-point font size. 

Recording Procedures. Recording of speech samples took place 

in a quiet room located at the New Voice Club of Hong Kong 

with the background noise level kept below 45 dB (Aweighted) 

(hereinafter dBA) as measured by a sound level meter. 

All the speech samples were recorded using a Sony 

MZ-R909 Mini-Disc Digital recorder (Tokyo, Japan) with a Shure 

SM48 dynamic microphone (Niles, Illinois) held 10 cm away 

from the center of the speaker’s mouth. Each speaker was given 

a brief practice period to become familiar with the speech materials, 

recording instructions, and procedures before the actual 

recording. To ensure that the quality of the recorded speech 

samples was representative of the speaker’s daily communication 

speech, a randomly selected sample from the recordings 

of each participant was played back to that individual. They 

were asked to judge if the recorded speech sample was representative 

of the quality of their daily communication speech. 

If the played-back sample was judged to be not representative 

by the individual speaker, the recording procedure was repeated 

until a representative sample was recorded. 

In the recording of the sentences from the CSIT, 16 the sentence 

list to be read was placed in front of each individual. The 

participants were instructed to read each of the 22 sentences 

as clearly as possible. The order of sentences to be recorded 

was randomized to avoid any possible order effect. Also, to avoid 

any reading errors owing to misreading of words, the following 

procedures were used. First, the investigator (I.K.-Y.L.) 

would indicate to the speaker each sentence to be read by pointing 

to the respective sentence. The speaker was asked to read 

the indicated sentence together with the investigator once. Then 

the investigator read the sentence aloud alone once, followed 

by the speaker, who read the sentence aloud alone once. This 

final attempt by the speaker was recorded. If any obvious reading 

error was noted in the recording, that sentence would be 

recorded again. 

Listeners. Six native Cantonese-speaking adults served as judges 

to transcribe and rate the speech samples. Three of them were 

25 to 33 years old (younger judge group), and 3 others were 

60 to 65 years old (older judge group). They were asked to transcribe 

and provide perceptual ratings of speech impairment for 

all the speech samples. All judges had no prior exposure to individuals 

who had undergone a laryngectomy and were alaryngeal 

speakers. They were not aware of the content of the 

speech materials used in the study before the listening tasks. 

All of them passed a hearing screening test at a threshold level 

of 20-dB HL at each octave frequency (250-8000 Hz). 

Listening Tasks 

A Sony CMT-JST MD high-fidelity sound system was used to 

play all the recorded speech samples to each individual judge 

with the speakers at a distance of 2 m in a quiet room (with a 

background noise level 45 dBA as measured by a sound level 

meter). The intensity level of the playback was adjusted by in- 

dividual judges to a comfortable level. The order of the alaryngeal 

speakers and the recorded sentences of each speaker was 

played back at a randomized order across listeners to avoid any 

possible order effect. 

Each of the 6 judges scored each alaryngeal speaker individually. 

They were asked to judge speech samples of the CSIT first. 

They were instructed to orthographically transcribe the 22 sentences 

and rate the severity of speech impairment of each speaker 

based on the speech samples on an 11-point (0-10) equalappearing 

interval (EAI) scale with 0 corresponding to no speech 

impairment and 10 corresponding to very severe speech impairment. 

In the orthographic transcription task, the judges were first 

asked to listen to all 22 sentences together once and then listen 

to each of the sentences a second time, pausing between 2 sentences 

whenever necessary, to transcribe each sentence word by 

word on the score sheets. The guideline suggested by Yorkston 

and Beukelman 17 was followed; that is, judges were not allowed 

to listen to each sentence more than 2 times and were encouraged 

to guess at words that were not completely understood. 

Each judge was required to repeat these tasks for 40 randomly 

selected speaker sample sets (ie, 80% of the total number 

of speaker sample sets) 2 weeks after their first listening 

task. This procedure was to establish the intrajudge reliability. 

The interjudge reliability was established by correlating the 

intelligibility scores transcribed by an individual judge with the 

other 2 judges within the younger and older judge groups. 

Communication-Related QOL 

Each participant also completed the Communication Activity and 

Participation After Laryngectomy 18 (CAPAL) questionnaire 

(Figure) to evaluate the extent of communication-related QOL 

deterioration in alaryngeal speakers. This profile was developed 

using the International Classification of Functioning, Disability, 

and Health (ICF) framework, 19 which evaluates the communication-related 

QOL in individuals who have undergone laryngectomy 

and experienced 3 levels of disablement, namely, speech 

impairment, communication activity limitation, and communication 

participation restriction. The CAPAL 18 has been shown to 

be a valid and reliable tool. In short, content validity was established 

using focus groups composed of alaryngeal speakers (n=15), 

their relatives (n=24), and speech therapists (n=10). They were 

asked to finalize the appropriate items to be included in the final 

version. Construct validity was established by comparing CAPAL 

results with 2 validated self-administered questionnaires: the Chinese 

version of the Medical Outcomes Study 36-item Short- 

Form Instrument 20 and the Chinese-Cantonese version of the Hospital 

Anxiety and Depression Scale 21 using Pearson r correlation 

coefficients. Significant correlations that varied from 0.26 to 0.6 

were found between the CAPAL and the other 2 questionnaires 

(P.05 for all comparisons). The internal consistency showed a 

Cronbach coefficient of 0.98 and a test-retest reliability of 0.84. 

Responses to each item were collected using an 11-point (0- 

10) EAI scale. Respondents were asked to put a cross on the 

point that best represented their response, with 0 corresponding 

to never and 10 corresponding to always. 

DATA ANALYSIS 

Calculation of Speech Intelligibility and 

Acceptability Scores 

The speech intelligibility score was obtained by dividing the 

number of correctly transcribed words by the total number of 

words (220). For each individual speaker, a total of 6 speech 

intelligibility scores were obtained, 3 from the younger judge 

group and another 3 from the older judge group. The mean 


706 



Self-perceived Ratings of Speech Impairment 

1. How severe do you think is your speech impairment? 

Daily Communication 

2. How often does someone you are familiar with (eg, spouse/family members) ask 

you to repeat in face-to-face conversation because of not understanding your 

speech? 

3. How often have you avoided talking to someone you are familiar with 

(eg, spouse/family members) face-to-face because of your speech impairment? 

4. How often does someone who has regular contact with you (eg, relatives/ friends) 

ask you to repeat in face-to-face conversation because of not understanding your 

speech? 

5. How often have you avoided talking to someone who has regular contact with you 

(eg, relatives/friends) face-to-face because of your speech impairment? 

6. How often do strangers ask you to repeat in face-to-face conversation because of 

not understanding your speech (eg, ordering in a restaurant)? 

7. How often have you avoided talking to strangers face-to-face because of your 

speech impairment (eg, ordering in a restaurant)? 

8. How often does someone you are familiar with (eg, spouse/family members) ask 

you to repeat in telephone conversation because of not understanding your speech? 

9. How often have you avoided talking to someone you are familiar with 

(eg, spouse/family members) on phone because of your speech impairment? 

10. How often does someone who has regular contact with you (eg, relatives/friends) 

ask you to repeat in telephone conversation because of not understanding your 

speech? 

11. How often have you avoided talking to someone who has regular contact with you 

(eg, relatives/friends) on phone because of your speech impairment? 

12. How often do strangers ask you to repeat in telephone conversation because of not 

understanding your speech (eg, government service hotlines)? 

13. How often have you avoided talking to strangers on phone because of your speech 

impairment (eg, government service hotlines)? 

14. How often does your speech impairment affect you talking in noisy environment 

(eg, in a Chinese restaurant)? 

15. Have you avoided talking in noisy environment because of your speech impairment 

(eg, in a Chinese restaurant)? 

16. How often does your speech impairment affect you talking in quiet environment 

(eg, in the library)? 

17. How often have you avoided talking in quiet environment because of your speech 

impairment (eg, in the library)? 

18. How often does your speech impairment affect you talking in groups? 

19. How often have you avoided talking in groups because of your speech impairment? 

20. How often does your speech impairment affect you to express your emotions 

verbally? 

21. How often have you avoided expressing your emotions verbally because of your 

speech impairment? 

Figure. Communication Activity and Participation After Laryngectomy questionnaire. 18 

speech intelligibility scores given to each speaker by both the 

younger judges and the older judges were compared. 

Calculation of the CAPAL Scores 

The item scores were computed to obtain the following section 

scores: 

1. Self-perceived speech impairment score (1 item, maximum 

score=10) 

2. Daily communication section score (20 items, maximum 

score=200) 

3. Social communication section score (6 items, maximum 

score=60) 

4. Job section score (4 items, maximum score=40) 

5. Emotion section score (14 items, maximum score=140) 

6. Total CAPAL score (the sum of the 5 section scores) 

(maximum score=450) 

Within each section of the daily communication, social communication, 

and job sections, items were organized in pairs; 

the first item addressed activity limitation, and the second item 

addressed participation restriction. Therefore, 2 additional scores 

were computed for each of these 3 sections: 

Social Communication 

22. How often does your speech impairment affect you making new friends? 

23. How often have you avoided making new friends because of your speech 

impairment? 

24. How often does your speech impairment affect you talking in your usual leisure 

activities (eg, playing mahjong, hiking, playing chess)? 

25. How often have you avoided talking in your usual leisure activities because of your 

speech impairment? 

26. How often does your speech impairment affect you talking in social gatherings 

(eg, gatherings with friends and ex-colleagues)? 

27. How often have you avoided talking in social gatherings because of your speech 

impairment? 

Job 

28. Does the speech impairment affect your working performance? 

29. How often have you thought of quitting/changing your job because of your speech 

impairment? 

30. Does the speech impairment increase your stress at work? 

31. How often have you avoided working because of your speech impairment? 

Emotion 

32. Do you feel embarrassed when you are talking to someone you are familiar with 

(eg, spouse/family members)? 

33. Do you feel embarrassed when you are talking to someone who has regular contact 

with you (eg, relatives/friends)? 

34. Do you feel embarrassed when you are talking to strangers? 

35. Do you feel upset when you are talking to someone you are familiar with 


36. Do you feel upset when you are talking to someone who has regular contact with you 

(eg, relatives/friends)? 

37. Do you feel upset when you are talking to strangers? 

38. Do you feel tense when you are talking to someone you are familiar with 


39. Do you feel tense when you are talking to someone who has regular contact with you 

(eg, relatives/friends)? 

40. Do you feel tense when you are talking to strangers? 

41. Do you feel low self-esteem when you are talking to someone you are familiar with 


42. Do you feel low self-esteem when you are talking to someone who has regular 

contact with you (eg, relatives/friends)? 

43. Do you feel low self-esteem when you are talking to strangers? 

44. Does your speech impairment affect your self-image (how you think of yourself)? 

45. Does your speech impairment affect your communication-related characteristics? 

1. Communication activity limitation (CAL) scores: the sum 

of scores from the first items of the paired questions within each 

section. The sum of CAL scores from the 3 sections resulted in 

the total CAL. 

2. Communication participation restriction (CPR) scores: 

sum of scores from the second items of the paired questions 

within each section. The sum of CPR scores from the 3 sections 

resulted in the total CPR. 

RESULTS 

PERCEPTUAL RATINGS 

OF SPEECH IMPAIRMENTS 

Table 2 lists the perceptual ratings of alaryngeal speakers’ 

speech impairment by the 2 groups of judges. The 

mean ratings from younger and older judges were 7.1 and 

5.3 (maximum score=10), respectively, which are significantly 

different (df, 96; t, 5.25; P.001), indicating 

that older judges perceived the alaryngeal speech to be 

less severe than younger judges. 


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Table 2. Perceptual Ratings of Alaryngeal Speakers a 

Group 

ES EL TE PD 

F3,45 

Younger judges 8.43 (0.98) 7.5 (0.86) 7.62 (0.87) 4.73 (1.03) 37.52b Older judges 7.14 (0.69) 4.5 (1.10) 6.38 (0.77) 3.20 (1.08) 39.14b There were also significant differences in the perceptual 

ratings between the different alaryngeal 

speaker groups within the younger and the older 

judge groups (1-way ANOVA: F3,45=37.52 [younger 

judges]; F 3,45=39.14 [older judges]; P.001 for both 

comparisons). Post hoc Scheffe tests revealed that the 

PD speaker group received significantly lower severity 

impairment ratings than the other groups of speakers 

(P.001 for all comparisons) from both the younger 

and the older judges. 

SPEECH INTELLIGIBILITY SCORES OF THE 

CANTONESE SENTENCE INTELLIGIBILITY TEST 

Table 3 lists the speech intelligibility scores of the 

CSIT 16 obtained by different speech groups. For both 

the younger and the older judges, there were significant 

differences in the CSIT scores among the alaryngeal 

speaker groups (1-way ANOVA: F3,45=38.54 [younger 

judges]; F3,45=36.00 [older judges]; P.001 for both 

comparisons). Post hoc comparison using Scheffe tests 

revealed that the PD speaker group received the highest 

CSIT score compared with the other groups of alaryngeal 

speakers (P.001 for all comparisons) from both 

group of judges. 

In the orthographic transcription tasks of the CSIT, 

reliability was assessed by Pearson r correlation coefficients. 

The intrajudge reliability of the older judge group 

was 0.74 (P=.001), and the interjudge reliability ranged 

from 0.64 to 0.72 (P=.001). For the younger judge group, 

the intrajudge reliability was 0.86 (P=.001), and the interjudge 

reliability ranged from 0.78 to 0.84 (P=.001). 

When comparing the speech intelligibility scores obtained 

from the younger judges and the older judges, the 

younger judges demonstrated a significantly higher score 

than the older judges (df, 96; t, 5.25; P.001). 

Perceptual Rating According to Alaryngeal Speech Mode 

Abbreviations: EL, electrolarynx; ES, esophageal; PD, pneumatic device; TE, tracheosophageal. 

aThe ratings, given as means (SDs) were made on an 11-point equal-appearing interval scale, with 0 indicating no speech impairment and 10, severe speech 

impairment. 

bP.001. Table 3. Cantonese Sentence Intelligibility Test Scores of Alaryngeal Speakers a 

Score According to Alaryngeal Speech Mode 

Group 

ES EL TE PD 

F3,45 

Younger judges 59.73 (7.97) 77.3 (7.01) 61.5 (6.82) 91.2 (4.80) 38.54b Older judges 56.9 (6.30) 62.0 (8.90) 59.1 (11.11) 79.7 (7.40) 36.00b Abbreviations: EL, electrolarynx; ES, esophageal; PD, pneumatic device; TE, tracheosophageal. 

a Maximum speech intelligibility score=100. Data are given as means (SDs). 

b P.001. 

PERCEIVED COMMUNICATION-RELATED QOL 

AFTER LARYNGECTOMY 

Table 4 lists the 5 section scores and total CAPAL scores 

in the different alaryngeal speech groups. It should be 

noted that in the analysis, data in the job section were 

excluded because only 5% of the total participants (3 of 

63) responded to the job section. Most of the participants 

were either retired or unemployed at the time of 

testing. Results of 1-way ANOVA revealed significant differences 

in the daily communication section score 

(P=.006), emotion section score (P=.04), and the total 

CAPAL score (P=.01). Electrolaryngeal speech scored the 

highest, whereas TE speech scored the lowest in the 4 

speaker groups for these 3 scores. Post hoc Scheffe tests 

of these 3 scores further indicated that differences between 

EL and TE speech were statistically significant (daily 

communication section score, P=.02; emotion section 

score, P=.04; total CAPAL score, P=.02). 

Table 5 lists the CAL scores of different speech groups. 

Results of 1-way ANOVA revealed significant differences 

in daily communication (P.01) and total score 

(P.01) among different alaryngeal speaker groups. Electrolaryngeal 

speech scored the highest, whereas TE speech 

scored the lowest among the 4 speaker groups. Post hoc 

Scheffe tests of these 3 scores further indicated that differences 

between EL and TE speech were statistically significant 

(P.01). 

Table 6 lists the CPR scores. Significant differences 

were found with daily communication (P.01) and total 

scores (P.01) among the 4 alaryngeal speaker groups. 

Electrolaryngeal speech scored the highest, whereas PD 

speech scored the lowest among the 4 speaker groups. 

Post hoc Scheffe tests of these 3 scores further showed 

that differences between EL and PD speech were statistically 

significant (P.01). 


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Table 4. Communication Activity and Participation After Laryngectomy (CAPAL) Questionnaire Scores of Alaryngeal Speakers a 

Questionnaire Section 

ES EL TE PD 

F3,45 

Self-perceived speech impairment, max score=10 2.00 (2.24) 2.93 (2.70) 2.08 (1.32) 2.93 (2.52) 0.59 

Daily communication, max score=200 59.00 (32.92) 81.86 (45.63) 37.31 (33.31) 42.00 (22.23) 4.68b Social communication, max score=60 23.14 (13.45) 24.14 (17.97) 10.46 (16.52) 18.67 (18.62) 1.61 

Job, max score=40 NAc 17.00 (5.66) 10.00c NAc NAd Emotion, max score=140 23.00 (24.69) 38.36 (28.17) 11.85 (17.81) 29.20 (18.87) 3.27e Total, max score=450 107.14 (67.78) 164.29 (83.87) 72.70 (57.71) 92.80 (54.22) 3.98b COMMENT 

SPEECH INTELLIGIBILITY AND ACCEPTABILITY 

OF ALARYNGEAL SPEECH MODES 

One of our objectives was to compare the speech intelligibility 

and acceptability among different alaryngeal 

speaker groups. Results revealed that PD speakers had 

the highest speech intelligibility and acceptability scores 

compared with those using the other 3 alaryngeal 

speech methods. This finding is consistent with that 

reported from studies 11,14 on lexical tone production 

among Cantonese-speaking alaryngeal speakers. Ching 


Abbreviations: EL, electrolarynx; ES, esophageal; max, maximum; NA, not available; PD, pneumatic device; TE, tracheosophageal. 

a Data are given as means (SDs) except where indicated. 

b P.01. 

c There is no standard deviation for this score. 

d Analysis of variance result for the job score was not available owing to the limited number of participants. 

e P.05. 

Table 5. Communication Activity Limitation (CAL) Scores of Alaryngeal Speakers a 



ES EL TE PD 

F3,45 


Job, max score=20 NAc 12.00 (1.41) 5.00c NAc NAd Total, max score=150 43.57 (24.54) 64.78 (28.39) 27.92 (18.66) 34.93 (17.83) 4.35b Abbreviations: EL, electrolarynx; ES, esophageal; max, maximum; NA, not available; PD, pneumatic device; TE, tracheosophageal. 

a Data are given as means (SDs) execpt where indicated. 

b P.01. 


d Analysis of variance result for the job section score was not available owing to the limited number of participants. 

Table 6. Communication Participation Restriction Scores of Alaryngeal Speakers a 



ES EL TE PD 

F3,45 


Job, max score=20 NAc 5.00 (7.07) 5.00c NAc NAd Total, max score=150 38.57 (22.59) 58.21 (32.02) 30.85 (33.99) 25.73 (20.16) 3.00b Abbreviations: EL, electrolarynx; ES, esophageal; max, maximum; NA, not available; PD, pneumatic device; TE, tracheosophageal. 

a Data are given as means (SDs) except where indicated. 

b P.05. 


d Analysis of variance result for job section score was not available owing to the limited number of participants. 

et al 11 found that PD speakers had the highest lexical 

tone intelligibility, whereas Yiu et al 14 also showed that 

both PD and TE speakers were more efficient in conveying 

lexical tone. The present findings provide further 

support to the contention that lexical tone production 

is critical in determining the speech intelligibility 

of Cantonese-speaking alaryngeal speakers. 

In comparing the speech intelligibility scores of 

CSIT 16 obtained from Cantonese alaryngeal speakers in 

the present study with the scores obtained from other 

nontonal language studies using the AIDS, 17 the 

Cantonese-speaking alaryngeal speakers as a whole 

seemed to show relatively lower speech intelligibility. 


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Bridges 6 reported a mean sentence intelligibility score of 

87.69% for English-speaking TE speakers and 81.71% 

for the ES speakers with naïve listeners. A higher intelligibility 

score (97.4%) was reported by McAuliffe et al 22 

with a group of TE speakers. One possible explanation 

for the discrepancy between the Cantonese- and 

English-speaking alaryngeal speakers might have been 

the nature of the lexical tone in Cantonese. Cantonese 

alaryngeal speakers would have to control the lexical 

tone variations in order to convey the verbal messages 

effectively. With an inability or difficulty in producing 

the lexical tone in some alaryngeal speech, the intelligibility 

would thus be lower. In fact, it has been reported 

that different alaryngeal speech methods are different in 

conveying lexical tones. 11,14 

Interestingly, younger listeners tended to understand 

alaryngeal speech relatively better but with a lower 

acceptability toward it. The present findings are similar 

to those reported by Clark, 10 who found that age of the 

listeners has a potential influence on the acceptability and 

understanding of alaryngeal speech. 

COMMUNICATION-RELATED QOL 

OF ALARYNGEAL SPEECH MODES 

Another objective of this study was to compare the communication-related 

QOL among speakers of the 4 alaryngeal 

speech modes. Although the PD speakers received the 

best speech intelligibility ratings, they did not perceive themselves 

as having the best communication-related QOL, as 

revealed by the CAPAL scores. The present results reveal 

that alaryngeal speakers who used TE speech methods received 

the lowest CAPAL scores (ie, the best communication-related 

QOL), followed by the PD speech. However, 

such differences between TE and PD speech were not statistically 

significant (P.05). The use of an external visible 

device in the PD speech method may have made it cosmetically 

less favorable than TE speech mode. Such a factor 

may have further imposed on the patient’s self-perception 

of communication efficiency, hence resulting in relatively 

poorer QOL. The present findings support the findings of 

the QOL studies, which used the ICF 19 framework. According 

to the ICF, 19 an impairment does not necessarily 

result in similar fashion of activity limitation and participation 

restriction. Therefore, causal relationship among the 

3 levels should not be assumed. In fact, it has been advocated 

that speech impairment in alaryngeal speakers does 

not necessarily reflect the extent of communication activity 

limitation and participation restriction. 23 This is borne 

out by our findings. 

CONCLUSION 

Findings from the present study shed light on the 

management of the communication-related QOL in 

alaryngeal speakers in general, although the data were 

obtained from the Chinese population. On the one 

hand, this study found that listeners of different ages 

had a considerable difference in their abilities in 

understanding and accepting alaryngeal speech. The 

younger the listeners, the easier it was for them to 

understand alaryngeal speech, but they had a lower 

level of acceptability toward it. On the other hand, the 

older the listeners, the more difficult it was for them 

to understand alaryngeal speech, but they had a better 

level of acceptability toward it. This finding highlights 

the need to consider the ages of the alaryngeal speaker’s 

significant others, relatives, and friends. In the 

clinical study of laryngectomy, the age of the listeners 

or judges in rating alaryngeal speech should be taken 

into consideration. 

Moreover, in postlaryngectomy speech rehabilitation, 

the choice of different alaryngeal speech methods 

for new alaryngeal speakers should be based on empirical 

data. The present results indicate that ES speakers 

present with the poorest speech proficiency, and EL 

speakers perceive the poorest communication-related 

QOL. Although PD speech, which is more popular in 

the Chinese-speaking community, seems to be superior 

owing to its higher speech intelligibility in Chinese and 

listeners’ acceptability ratings, TE speech reveals relatively 

better overall communication-related QOL than 

PD speech. Therefore, both TE and PD speech have 

their own advantages in the Chinese population. Considering 

that the ultimate goal in postlaryngectomy speech 

rehabilitation is to enhance an alaryngeal speaker’s QOL, 23 

we contend that TE speech achieves an overall more favorableoutcomeandQOLforChinesealaryngealspeakers.We 

also argue that this conclusion—TE speech achieves a 

better outcome—can be applied equally well to Western 

communities. 

Submitted for Publication: January 27, 2008; final 

revision received May 12, 2008; accepted May 23, 

2008. 

Correspondence: Edwin M.-L. Yiu, PhD, Voice Research 

Laboratory, Division of Speech and Hearing Sciences, 

University of Hong Kong, 5/F Prince Philip Dental 

Hospital, 34 Hospital Rd, Hong Kong (eyiu@hku 

.hk). 

Author Contributions: All of the authors had full access 

to all the data in the study and take full responsibility 

for the integrity of the data and the accuracy of the 

data analysis. Study concept and design: Law and Yiu. Acquisition 

of data: Law. Analysis and interpretation of data: 

Law and Ma. Drafting of the manuscript: Law and Ma. Critical 

revision of the manuscript for important intellectual content: 

Yiu. Statistical analysis: Ma. Obtained funding: Yiu. 

Administrative, technical, and material support: Law. Study 

supervision: Law and Yiu. 

Financial Disclosure: None reported. 

Funding/Support: This study was supported in part by 

a grant from the Voice Research Laboratory, University 

of Hong Kong (Ms Law). 

Additional Contributions: The New Voice Club of Hong 

Kong assisted with participant recruitment. 

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