71-7386

ALEO, Edward Louis, 1944- ASAI AS COMPARED TO AND THE SPEECH PRODUCED BY FIVE ARTIFICIAL LARYNGES.

The Ohio State University, Ph.D. , 1970 Speech Pathology

University Microfilms, Inc., Ann Arbor, Michigan

Copyright by

Edward Louis Aleo

1971 ASAI SPEECH AS COMPARED TO ESOPHAGEAL SPEECH AND THE

SPEECH PRODUCED BY FIVE ARTIFICIAL LARYNGES

A DISSERTATION

Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy in the Graduate School of The Ohio State University

By Edward Louis Aleo, B.S., M.A.

The Ohio State University 1970

Approved by

Advi sar Department pr Speech ACKNOWLEDGMENTS To cite each and every person who has contributed and helped make this study possible would take pages equal in number to this dissertation. The author expresses his most sincere thanks and gratitude to the laryngectomized patients who provided the recordings and to ray fellow students and friends who so graciously donated their time as listeners and judges. Acknowledgment is given to Dr. Gordon Monteith and his assistants, of the College of Dentistry, for their craftsman­ ship and help in designing and perfecting the prosthesis for the Tait Oral Vibrator.

Also, acknowledgment is given to Mr. Marshall Duguay of

The Department of Speech and Hearing at the State University College in Buffalo, New York, for his encouragement and loan of the various artificial devices employed in this study. Appreciation for the reproduction of various drawings used to illustrate significant aspects of this study is ex­ tended to Mrs. Sheila Greenawald. Indebtedness to Dr. Buth Beckey Irwin for her close and most constructive supervision of this study is hereby acknowledged..

A very special thanks is directed to my parents Mr. and

ii Mrs. Joseph P. Aleo and my brothers Tom and Joe for their consistent encouragement and backing throughout my endeavors to obtain and complete my formal education.

There isn’t a word that encompasses or can describe my appreciation for the patience, help, guidance, companionship, and love of the one person, my wife Sue, who has been my motivation and most important single factor in the completion of my graduate program. Acknowledgment, love and welcome are extended to our son,

Edward Louis, for his arrival (six days late) on August 11,

1970.

iii VITA

Personal Born in Rochester, New York, March 8, 19^4.

Married to Sue Ann (Peeler) Aleo, June 10, 196?•

Children: Edward Louis Aleo, Jr., born August 11, 1970*

Academic Degrees B.S. Idaho State University 1966 Speech Pathology and Audiology

M.A. The Ohio State University 1968 Speech and Hearing Science

Training and Professional Experience

The Ohio State University 1966 V.R.A. Traineeship; Diagnosis and treat­ ment of speech and hearing disorders

The Ohio State University 1967 Research Associate, Project LIFE; con­ struct program material to be used in teaching the deaf

The Ohio State University 1968 American Cancer to Society Fellow; present Supervisor, The Clinic

Elmira College June, Director of Speech 1970 and Hearing Clinic, Elmira College, Elmira, New York

iv VITA - Continued•

Research - Unpublished An Exploratory Study Investigating Three Modalities of Constructed Response of Programmed Language Material for the Hearing Impaired Child

The Effects of Delayed Side tone on the Duration of the Speech of the Cerebral Palsy and Non-Cerebral Palsy Speakers. M.A. Thesis, 19o8.

v TABLE OF CONTENTS

Page

ACKNOWLEDGMENTS ...... ii

VITA ...... iii

CHAPTER I. INTRODUCTION ...... 1 Statement of The Problem ...... 3 Definition of Terras ...... 4 Organization of S t u d y ...... 5 II. REVIEW OF LITERATURE ...... 6

Incidence ...... 6 Diagnoses and Classifications ...... 10 T r e a t m e n t ...... 11 Physiology of Esophageal Speech ..... 11 Types of Speech ...... 12 Methods of Air I n t a k e ...... 12 Esophageal ...... 14 Factors Influencing Intelligibility of Speech ...... 15 ...... 17 S u m m a r y ...... 22

III. METHODS AND PROCEDURES...... 23 Experimental Speakers...... 23 Selection of Listeners ..... 24 Recording Procedures ...... 25 Recording of The D a t a ...... 26 Summary ...... 27 IV. RESULTS AND DISCUSSION...... 2b

The Mull Hypotheses ...... 2b Statistical Treatment...... 29 Analyses of D a t a ...... 30 S u m m a r y ...... 41

vi Page

CHAPTER V. SUMMARY AND CONCLUSIONS...... 42 The Null Hypotheses ...... 42 Results ...... 43 Conclusions...... 46 Implications for Further Investigation. . 47

BIBLIOGRAPHY ...... 4S APPENDICES ...... 54 Appendix A ...... 55 Appendix B ...... 5y

vii LIST OP TABLES

Table Page I. Smoking Habits of Sixty-four Patients Diagnosed as Having Laryngeal Carcinoma 8 II. Age and Incidence of Sixty-four Patients Diagnosed as Having Laryngeal Carcinoma 9 III. The Type I Analysis of Variance for Seven Treatments and Three Groups of Judges . 33 IV. The Type I Analysis of Variance for Seven Treatments and Three Groups of Judges . 3^ V. Newman-Keuls Critical Difference Test for the Multiple-Choice Intelligibility Tests ...... 37

V I . Newman-Keuls Critical Difference Test for the Seven-Point Hating Scale . . . . 38

viii LIST OF FIGURES

Figure Page

I. Occurrence of Carcinoma of the in Various Decades of L i f e ...... 9 II. Mucosal Tunnel in the Conley Operation . 21a

III. Asai, Three Stage O p e r a t i o n ...... 21b

ix CHAPTER I

INTRODUCTION

The is one of the essential assets to the communi­ cative and social processes. Due to a sharp increase in the incidence of cancer of the larynx, a keener understanding of methods of speech rehabilitation for the laryngectomized patient is needed. The method chosen should allow immediate attention to restoring the patient to pre-operative economic, social, and psychological status as quickly as possible.

It has been stated by Creech (1966), Levin (1952, 1967), and Lauder (1969) that of the methods available to the laryn­ gectomee, esophageal speech is the most desirable method of communication. Hyman (1955) found that there was no signif­ icant difference in the scores obtained on Blackfs (1957)

Multiple-Choice Intelligibility Tests between esophageal speech and speech when an artificial larynx was used. In another study, McCroskey and Mulligan (1963) found that naive listeners obtained higher intelligibility scores for users of the artificial larynx than for esophageal speakers. These results were in opposition to the experiences of the speech therapists, who found esophageal speech to be significantly more intelligible than when an artificial larynx was used.

The authors noted that the speech pathologists may have been influenced by professional training or bias.

Lauder (1968, 1969) emphasized that esophageal speech was the best method of communication available to the laryn­ gectomee. In 1970, Lauder published an article in which he was less emphatic about teaching esophageal speech. The immediate need for vocal rehabilitation for the speechless laryngectomee was stressed as being of the utmost importance. In addition to the economic and social demands to speak, in time of emergency the speech produced with the aid of an artificial larynx is immediate and adequate.

In reviewing the literature, there was no statistical data available indicating that the use of the artificial larynx interferes with learning esophageal speech. The early employment of the artificial larynx may lessen the anxiety and frustration of not being able to communicate readily; moreover, the artificial larynx may even aid the laryn­ gectomee in the learning of esophageal speech by producing a more relaxed and less demanding learning atmosphere. Duguay (1968) studied the intelligibility of seven different artificial and esophageal speech. He con­ cluded that esophageal speech was significantly more intelli­ gible than the artificial devices used. It was noted that the Super Aurex Electrolarynx and Cooper-Hand Artificial

Speech Aid were considered adequate equipment in introducing a laryngectomee to artificial speech aids.

Since many authors (Duguay, 1968; Lauder, 1968, 1969; and Levin, 1952, 1967) have found esophageal speech to be superior, it may be reasonable to suspect that intelligi­

bility of various artificial aids, esophageal speech, and Asai speech (Miller, 1967, 1968) may warrant further investi­

gation. If Asai speech is judged to be more intelligible than

other methods of alaryngeal speech, or one artificial device

is judged to be more intelligible than others, then it may be important information in deciding the course of speech

rehabilitation for the laryngectomized patient.

Statement of the Problem

The purpose of this study was to investigate the

intelligibility of seven different methods of producing

alaryngeal speech as evaluated by various listeners on cer­

tain listening tasks.

The specific questions proposed for study were as

follows: 1. Do intelligibility scores of various types of

alaryngeal speech differ when measured by Black's Multiple-

Choice Intelligibility Tests (1957)? 2. Do three groups of listeners, varying in experience with laryngectomized speech rehabilitation, differ in

intelligibility scores obtained on the Multiple-Choice

Intelligibility Tests? 3. Do the intelligibility ratings of various types of alaryngeal speech differ when measured by a seven-point rating scale of intelligibility? 4. Do three groups of listeners, varying in experience with laryngectomized speech rehabilitation, differ in the intelligibility ratings (seven-point) based on words spoken from the Multiple-Choice Intelligibility Tests? 5. Is there a relationship between the scores obtained on the Multiple-Choice Intelligibility Tests and the ratings

(seven-point) of intelligibility based on words spoken from the Multiple-Choice Intelligibility Tests for the twenty- eight alaryngeal speakers?

Definition of Terms

The terms used in this investigation are defined as follows: 1. Alaryngeal speech: Speech produced after the re­ moval of the larynx. 2. Artificial larynx: Any appliance that produces sound, upon initiation by the subject, which can be substituted for the vocal cords in the communicative process.

3 . Asai technique: An operation for producing speech by the construction of a dermal tube between the tracheo- stoma and a fistula leading-into the pharyngeal cavity. When the tracheostoma is occluded, expired air passes up the dermal tube; vibration takes place and sound is transmitted into the . Esophageal speech: produced and articulated 5 when the upper third of the esophagus vibrates. 5. Intake of air: Any procedure used to force air into

the air reservoir for producing esophageal speech.

Organization of Study

Chapter I contains the introduction, the statement of the problem, questions proposed for study, and a definition

of terms. The review of literature will be presented in Chapter II. Chapter III will contain a discussion of the procedures used in the study. The results will be discussed

in Chapter IV which is followed by the summary and conclu­

sions in Chapter V. CHAPTER II

REVIEW 0? LITERATURE

The purpose of this study was to investigate the effects

of seven different types of alaryngeal speech on intelligi­

bility when judged by three groups of listeners. The discus­ sion of this chapter will occur under these headings:

incidence, diagnoses and classifications, treatment, physi­

ology of esophageal speech, types of speech, methods of air intake, esophageal speech production, factors influencing

intelligibility of speech, and alaryngeal speech.

Incidence

Throughout history men have died as a result of cancer

of the larynx. The first attempt to combat laryngeal

carcinoma was made by Billroth on December 31, ltf?3 (St.

Clair Thomson, 1939)* In 1&75, Bottini of Turin was cred­ ited with the first laryngectomy. His patient lived several years after the operation (St. Clair Thomson, 1939)* Statistics for the American Cancer Society projected that

the incidence of cancer would be 3 or 4 per 100,000 with 3,000 to 4,000 performed annually (Jackson and Mor­ ris, 1902). This number is added to the 25,000 - 35,000

6 estimated by Hagulies (1965) to be living in the United

States. Cancer, like death, has no regard for age, sex, or race.

Carcinoma of the larynx occurs more frequently in the late middle-aged male (American Cancer Society, I960), but it has been diagnosed in children in their first decade of life

(Gardner, 1962). As the number of females who smoke has in­ creased, so has the incidence of laryngeal carcinoma in women increased. It was projected that laryngeal carcinoma in women constituted approximately 3 per cent, but this figure has risen considerably higher (American Cancer Society, i960).

National Cancer Institute (Jackson, 1962) showed a 75 per cent increase in the incidence of cancer in general popula­ tion from 1953 to 1963 with the mortality rate up to 42 per cent during this same period. ■ Studies by King (1968) point out that the occurrence of cancer in the Caucasoid race is much greater than in the

Negroid race. In hospitals where equal numbers of both races were observed, 85 per cent of the patients with cancer of the larynx were Caucasoid. King (1968), Yen Chen and others (1963) refer to studies which imply that a positive correlation betvreen smoking and cancer of the larynx exists

(Table I). 8

TABLE I

Smoking Habits of Sixty-four Patients Diagnosed as having Laryngeal Carcinoma (Yen Chen, 19°3)

Types No. of Patients Per Cent

Cigarettes 1 uaclc/day 30 k? 2 packs/day 20 31 3 packs/day k 7 Cigar 1 1 Pipe 2 3 Unknown 5 8 None 2 3 Total 6k 100

Their findings agreed with others (Yen Chen, 1963; King, 1968), that the incidence of cancer of the larynx was greatest in the fifth and sixth decades of life (Table II and

Figure I).

Auerback (United States Department of Health, Education, and Welfare, 1969) investigated the histology of 9^2 men who were treated in a single hospital from 1964- to 1967* He com­ piled the smoking histories for all cases. Results indicated that of the 88 who had never smoked, 75 pe** cent had no cells with atypical nuclei. The 116 ex-smokers showed histologies similar to non-smokers. Only one of the 9k cigar and/or pipe smokers showed no atypical cells. Of the remaining 6kk cases who smoked 9 cigarettes, none were free of atypical nuclei.

TABLE II

Age and Incidence of Sixty-Pour Patients Diagnosed as having Laryngeal Carcinoma (Yen Chen, 1963)

Age No. of Patients Per Cent

30 - 39 2 3.2 4o - 49 14 22.0 50 - 59 22 34.3 60 - 69 22 34.3 70 - 79 4 6.2 Total 64 100.0

50 Surgery for Laryngectomies in General Population rH Ctf (by decades) n -P 40 Surgery for O / ‘ EH Laryngec­ tomies in

20 30 TfO 50 SO" To W Age in Years Fig. I. Occurrence of Carcinoma of the Larynx in Various Decades of Life (King, 1968) 10

Diagnoses and Classifications

Early diagnosis of is an important factor in improving the survival rate. To facilitate early

diagnosis, programs to educate the public of the symptoms of

cancer is vital. Initial symptoms, such as hoarseness, sore

throat, problems with breathing, a lump in the throat or on

the side of the neck, should be included in a program to

educate the patients and to help physicians to make early and accurate diagnoses which may save lives. Diagnosis having been made, the location and size of the tumor is important. Until 1963# cancer of the larynx was classified as either intrinsic or extrinsic. Intrinsic carcinoma implies that the tumor was confined within the borders of the larynx. .Extrinsic carcinoma may invade the structures that attach to or communicate with the larynx, for example the sternohyoid and omohyoid muscles. Under the direction of the American Joint Committee for Cancer Staging and End Results Reporting (1963), a tumor may be anatomically described by considering (1) its location, whether supra- glottic, glottic, or sub-glottic; (2) the inclusion of the regional lymph nodes; and (3) the extent of matastasis. From the classification of clinical stages, the physician is able to describe topographically a tumor as being in one of five stages rather than describing it as intrinsic or extrinsic cancer. Itfithin these stages, there may be various combina­ tions specifying the laryngeal malignancy. 11

Treatment

The selection of treatment is based on the information obtained from the anatomical classification. Accordingly, the treatment may be surgery, radiotherapy, or a combination of both.

The extent of tumor growth dictates the type of surgery.

It is generally agreed that x-ray or radiotherapy alone may be employed in cases of small laryngeal carcinomas. In more extensive carcinoma growth, surgery, ranging from a partial laryngectomy to total extirpation with radical neck dissec­ tions, is offen combined with radiotherapy. Present thinking concerning combination treatment falls into three main cate­ gories: (1) x-ray therapy used prior to surgery to arrest the spread of the carcinoma; (2) surgery to remove the carcinoma followed by x-ray therapy; and (3) surgery with both pre- and post-operative radiation therapy.

Physiology of Esophageal Speech

Eallen (193*0 believed that the reservoir of air for the production of esophageal speech was the stomach. In a study by Froeshels (1951), he stated the esophagus could be the

"ideal air chamber for alaryngeal speech". Vrticka and Svobo- da (1961), Hoerr (Nilo, 1957) and Hoople (195*0 have reported that the most adequate site for the air reservoir is the entire esophagus or the upper third of the esophagus. 12

Types of Speech

The laryngectomized patient has approximately four anatomically different alaryngeal methods of producing

speech: (1) pharyngeal, (2) buccal, (3) esophageal, and (4) whispering. Pharyngeal speech is produced when the neoglottis is situated in the hypopharynx. Air passes by the constricted walls of the pharynx producing phonation which is very strained and tense in quality. Speech pro­ duced by forcing air by the cheeks and the alveolar ridge is called buccal or "Donald Duck" speech. I-Iany times, the sounds are not produced with this method. In esophageal speech the esophagus is the reservoir of the air

supply. As air passes through the cricopharyngus sphincter

(the mouth at the upper third of the esophagus), a neo­ glottis is produced. In whispered speech phonation is limited to voiceless consonants with the omission of voiced

sounds.

Methods of Air Intake

The major role of the speech therapist in the rehabili­ tation of the laryngectomee is to assist the patient in the production of esophageal speech. To produce esophageal speech the patient must first trap air within the esophagus. There are various methods of initiating phonation, and each method has been successful with esophageal speakers. Swallowing, 13 injection, and inhalation are the three methods or air intake

explained in the literature. Swallowing is the most primi-' tive method of trapping air. The patient is told to "swallow" air. Wallen (I960) states that the patient "... learns to compress air in the esophagus .and to release it quickly, pro­

ducing sound in the process." Levin (1963) correlates this method with "swallowing air by gulping or with the aid of

liquids."

The injection method is sometimes referred to as injection or "tongue popping". In a study by IIoolenaar-Bi j i

(1953) the importance of the in injecting air into the esophagus vras demonstrated. The tongue is placed in a position to produce a [d] or [t] sound. The back of the

tongue is then lifted and retracted as to produce a [k]

sound. Air is then forced into the esophagus. The term inhalation is sometimes used interchangeably with aspiration, inspiration, and insuffation. The esophagus

is simultaneously inflated as the patient takes a deep breath.

Upon inhalation, there is a decrease of negative pressure in the esophagus. Atkinson (1957) demonstrated that the esophagus at rest has several millimeters (mm.) of mercury

(Hg.) below atmospheric pressure. As the diaphragm is ex­ panded downward, the ribs move outward and upward increasing the amount of air within the esophagus to about -10 to -15 mm. Hg. As a partial vacuum is produced, the air within the mouth and pharynx rushes into the esophagus. 14

Esophageal Speech Production

The production of sound is explained by Snidecor (196b) as being a, " ‘largely . . . diaphragmatic action* through a narrow segment at the top of the esophagus which vibrates, thus serving as a basis for voice. Along with the movement of the diaphragm, one observes a narrowing of the esophagus from below, which may indicate a true muscular or antiperi- stalic movement." Five possible sites of vibration in the pharyno- esophageal region are defined by Diedrlch and Youngstrom

(I960). They consider the (1) cricopharyngeal muscle, (2) the inferior pharyngeal constrictor in opposition to the anterior pharyngeal constrictor, (3) the superior esophageal sphincter, (4) the lingual pharyngeal approximation, and (5) the medial constrictor forming transverse mucosal folds as potential sources of phonation. Diedrich and Youngstrom (1966) state phat the pharyno-esophageal segment is respon­ sible for most of the phonation.

The investigator in the present study would attempt to describe the production of speech in this manner: As air is forced into the esophagus, regardless of the method of intake, other anatomical structures prominent in inspiration come into play. Expansion and depression of the diaphragm causes inhalation through the stoma to occur. The abdominal and thoracic muscles expand outward causing the ribs to lift and move outward. The negative pressure within the esophagus 15 increases and a vacuum is produced. Air above the esophagus

is sucked into the esophagus. The patient then continues to hold the diaphragm in the position for inhalation while he builds up pressure within the abdominal and thoracic regions. This buildup of pressure is accomplished in a maimer similar to pressure buildup noted as one lifts a heavy weight or grunts. An increase of pressure forces the air within the pharyngeo-esophageal (P-E) segment to be passed through the upper third of the esophagus resulting in vibration. This could be accomplished without exhaling simultaneously through

the stoma.

Factors Influencing Intelligibility of Speech

Several methods of speech proficiency and associated

variables of motivation, age, personality, family environment, and education were investigated by Shames, Font, and

Matthews (1963)• Their results showed significant correla­ tion between the measure of speech proficiency and variables

studied. They concluded that age at the time of the opera­ tion, removal of strap muscles, intact crico-pharyngeal muscle, presurgical knowledge of esophageal voice production, and the number of speech lessons were significant variables in perfecting speech. The above study indicated that the age and education of the patient, and the role of the family were important factors in the rehabilitation of the laryngectomee. The source of esophageal speech training, whether by a speech therapist, a laryngectomee, or self-taught did not differen­ tiate "good" from "poor" esophageal speakers. Therefore, the authors suggested that the person responsible for teaching esophageal speech be competent and knowledgeable.

The most proficient esophageal speakers are hoarse and monotonous according to Martin (1963). He subjectively esti­ mated that fewer than 50 per cent of all laryngectomees ever acquire a reasonably adequate and socially acceptable esophageal voice. In contrast, Horn (1962) in a survey of 3,366 laryn­ gectomees found that 79 per cent learned to speak by one method or another. His investigation disclosed that 6^ per cent spoke entirely with esophageal voice, while of the re­ maining 36 per cent, 5 per cent employed both esophageal speech and artificial aids, 10 per cent spoke only with the use of an aid, 12 per cent did not speak at all, and 9 per cent "fall into various miscellaneous classes, or did not adequately state the present status of their speech".

Criteria necessary for good esophageal speech indicated by

Lauder are as follows: 1. Sufficient volume to be comfortably heard by a listener with normal hearing at a reasonable distance in a fairly quiet surrounding.

2. Intelligibility supported by clarity of articulation, expressiveness, pitch variation, phrasing, and adequate visual aids. 17 3. Phonation produced with breath control resulting in a smooth speech flow, naturalness of expression, and avoidance of stoma blast. 4. A reasonable speech rate of at least 80 to 100 words per minute.

5. Pew distracting speech mannerisms, facial grimaces, and inappropriate body movements during speech (Lauder, 1969, p.357). Pour learned phonatory skills are essential, according to Berlin (1963), for ultimately becoming a proficient esophageal speaker. These skills are: (1) the ability to phonate readily on demand, (2) maintaining a short latency between inflation of the esophagus and phonation, (3) main­ taining an adequate duration of phonation, and (4) ability to sustain phonation during articulation.

Alaryngeal Speech

The historical development of alaryngeal speech incom­ passes more than a century. The first mention in the liter­ ature of the artificial larynx was in 1859* Czermark in­ vented a device for a patient who became speechless due to complete chronic stenosis of the larynx (Hanson, 1940). Billroth performed the first laryngectomy in 1873, £UicL Gussenbauer devised an artificial larynx for the laryn- gectomized patient. In 1877, Stoerk (cited in Hanson, 1940), using a whistle, attached it to the trachea and the mouth. He later converted this aid so it attached to a bellows instead of the lungs. 18 Many other devices were used experimentally, but most of them were discarded because of their unfavorable quality, or because the communication between the source of vibration and the oral, nasal, or pharyngeal cavities was poor. In 1920, KcKenty (cited in Gardner and Harris, 1961) or New York invented a pneumatic aid which revolutionalized the artificial larynx. He placed a rubber band, as the reed, transverselly across a mouthpiece. Dr. McKenty later ob­ tained the help of the Western Electric Company and an inex­ pensive artificial reed-type larynx Type 1A was developed.

The electronic artificial larynx appeared in 1944

(Gardner and Harris, 1961). It was a product of the Wright- Aurex Corporation. The instrument was cylindrical in shape with a one-inch diaphragm located at one end. The cylinder was connected to a battery by a long cord. The National Hospital for Speech Disorders (Barney, I960), recognizing the expense and need for other artificial devices, set up the

Advisory Committee on Artificial Larynges. This Advisory

Committee asked Bell System to consider a program that would develop an electro-larynx. In 1959 Western Electric intro­ duced its new cylindrical shaped transistorized artificial larynx (Barney, 1959)• This model was to replace the Type 2A, a vibrating metallic reed, which had been on the market since 1929* In 1955, there existed only one electro-larynx and various pneumatic aids. Hyman (1955) became interested in 19 comparing the Western Electric Type 2A with esophageal

speech. The investigator's results indicated that, "...

in comparing the voices of the artificial-larynx and esophageal speakers, the artificial-larynx speakers were always preferred". The subjects found the artificial larynx to be more pleasant than esophageal speech. He also found that there was no significant difference in intelligibility between speakers using the two methods. Prior to the above study, Bangs, Lierle, and Strother

(1946) stated subjectively, that esophageal speech possessed a more natural quality which was less distracting, and that

the speakers were not dependent on an artificial aid subjected

to mechanical difficulties. Lauder (1966), in a questionaire to speech patholo­ gists, physicians, and laryngectomees asked whether they preferred esophageal speech or speech produced with artifi­

cial larynxes. He reported that the responses received varied, but most of them preferred esophageal speech. Some

considered the electronic aid as a crutch diminishing moti­ vation and psychologically demoralizing to the self image.

Others stated that those who use artificial larynxes prior to

learning esophageal speech do poorly in their esophageal speech training. The teaching of esophageal speech over the use of the

electro-larynx is supported by Levin (1952). He recommends that the artificial aid be used only when (1) stenosis of the esophagus occurs, (2) the cervical portion of the esophagus is removed because of tumor, (3) multiple handicaps exist, or (4) the patient exhibits senility or extreme lack of moti­ vation. Shames, Font> and Matthews (1963) explored the difference between esophageal speech and the speech produced with the artificial larynx when speech training variables, such as age, education family environment, were studied as correlates of speech proficiency. They stated that the above mentioned variables were independent of the method of alaryngeal speech employed. The authors reported that speech proficiency was related to age, education, extent of surgery, and the amount of time elapsing between surgery and the first speech lesson. Heported difficulty of adjustment for the family and the patient's assessment of his speech problem as being a source of embarrassment were two variables in which the esophageal group was significantly better than the users of the arti­ ficial larynxes. It was noted that the subjects in the artificial-larynx group had faster reading time, higher mean articulation and word-intelligibility scores, and a signifi­ cantly lower number of surd-sonant errors.

Improvements in both the artificial larynx and the methods of surgery have steadily increased. Although new devices became more plentiful, and esophageal speech more perfected, there were still those who were not satisfied.

Beck (1939) presented such a patient. Dissatisfied with 21

Bucco-esophageal speech, the patient created a fistula through the posterior wall of the trachea to the base of

the tongue. This was accomplished by inserting a heated ice pick through the tissue. Beck stated that it was, "... the

best voice I have ever heard in a laryngectomized patient."

Intrigued with the theory of establishing comraunication between the trachea and the esophagus, Conley (1958, 1959) constructed a tube of split-thickness skin graft (Figure II) and later used a vein graft. He reported that this procedure yielded an adequate voice with qualities very similar to esophageal speech.

In 1965, Dr. Byozo Asai, Kobe University, Japan, pre­ sented an unique three-stage procedure which upon completion exhibited very clear and intelligible speech (Figure III).

The Asai technique was first presented to the United States by Dr. Alden H. Hiller (1967). Miller reported that "... a dermal tube, buried under the skin of the midline of the anterior neck, from the upper end of the remaining trachea into the hypopharynx" (Miller, 1967, p. 829) was constructed. The Asai patient speaks by placing his finger over the stoma.

Air is exhaled from the lungs and travels up the dermal tube into the hypopharynx producing speech. Miller believed that the voices produced by this technique are "... far superior to esophageal voice ..." (Miller, 1968, p. 781).

The latest research reported in the literature describes a new surgical reconstruction of a simplified larynx. In Fig. 2. Mucosal tunnel opens into trachea, extends upward then interiorly. It is suspended on the omohyoid muscle -(Conley, 1958).

THGMtta

- o . T u w u e w - O m o\i yoii> TnuSCLE

T5.RC-H tfi

V\OC.oSfl s 21b

6

'U

a

£ W _ y n * n s Z % ° ^

O

u

U

Verma I T u b e n

Pig. 3* First stage, the major and minor stomata created (A); Second stage, the addition of the pharyngostoma (B); Third stage, dermal tube created and connected to the pharyngostoma (C). 22 reconstructing the larynx after a laryngectomy, Serafini

(1969) has attempted to abolish the tracheostoma, preserve normal deglutition, and restore phonation using expired air.

This surgical procedure performed on dogs and monkeys con­ sisted of (1) inferiorly, removal of the larynx at the first tracheal ring; (2) anteriorly, the larynx is separated from the hyoid bone and the epiglottis; (3) suturing the raised trachea to the hyoid bone and epiglottis stump. This surgi­ cal procedure resulted in the functioning of the epiglottis with no indications of aspiration of saliva. Spontaneous recovery of phonation appeared, though hoarse at first,

shortly after the operation.

Summary

The review of literature was undertaken with the intent of giving the reader an overvievr of what laryngectomy means, the implications of speech therapy, and the important role that the artificial larynx may play in speech rehabilitation of the laryngectomized patient. Definite interest has been portrayed in the literature in the comparing the Western

Electric Types #2A and artificial larynxes with esopha­ geal speech. Neither the intelligibility of several types of artificial larynges nor the intelligibility of esophageal speech versus Asai speech have been reported in the litera­ ture according to the review made by this investigator. CHAPTER III

METHODS AND PROCEDURES

The purpose of this study was to investigate the intelli­ gibility of seven methods of alaryngeal speech production. The stimuli were then evaluated by three groups of judges.

Included in the investigation was an attempt to determine whether a relationship existed between intelligibility as judged on the Multiple-Choice Intelligibility Tests and the seven-point rating scale. The experimental speakers, selection of listeners, recording procedures, and the recording of the data are described in this chapter.

Experimental Speakers Twenty-eight laryngectomees residing in Central Ohio were selected as speakers. There were 26 males and 2 fe­ males, ranging in chronological age from 4-5 to 69 with a mean age of 5^*9 years. All but 5 speakers had received group or individual speech training for not less than four months. Ten speakers had undergone a total laryngectomy; 13 speakers had undergone a total laryngectomy with a uni­ lateral neck dissection; while five speakers had undergone a total laryngectomy with bilateral neck dissection.

23 24

Three speech therapists experienced in esophageal speech training evaluated 35 recorded samples of alaryngeal speech, five representing each of the seven types of speakers. These three listeners were asked to choose the four most intelli­ gible speakers out of five for each of the groups. Only the four most intelligible speakers were used as subjects in this study. The remaining 28 alaryngeal speakers were divided into seven distinct treatment groups: (1) profi­ cient users of the Asai speech, (2) proficient users of esophageal speech, (3) proficient users of the Tait Oral Vibrator, (4) proficient users of the Cooper-Hand Electronic

Speech Aid, (5) proficient users of the Super Aurex Electro­ larynx, (6) proficient users of the VJestem Electric Vibra­ tor Type #5, and (7) proficient users of the Y/estern Electric

Pneumatic Heed Type #2A.

Selection of Listeners

There were three groups of ten judges each performing the listening tasks. The panels of judges consisted of :

(1) speech therapists, experienced with laryngectomized speech rehabilitation, (2) speech therapists, experienced but not with laryngectomized speech rehabilitation, and (3) naive listeners. The experienced listeners were either graduate student speech therapists, or speech therapists working professionally. The naive listeners consisted of those who were not familiar with the laryngectomized patient or were 25 not competent speech therapists.

Hecording Procedures

Each speaker read a different list from Black's Multiple-

Choice Intelligibility Tests. ' These stimuli were read into a Roberts 770X tape recorder at 3 3/^ inches per second.

Forty-eight word lists from Forms C, C-l, D,- D-l were ran­ domized and twenty-eight lists were distributed to the alaryngeal speakers. The three panels of ten judges lis­ tened to the tape of speakers. Before the Multiple-Choice Intelligibility Tests were administered, the following instructions were given to the judges: Nov; look at your answer form. You are going to hear a series of groups of three words. From your re­ sponses we can measure both the intelligibility of the individuals who read the words and your effi­ ciency as a listener in the communication situation. You will hear: 'I am Speaker 10. I say again, I ain Speaker 10. Number 1 mortar, shut, assist.1 You will notice that for each word that is read there are four possible choices on your answer form. You heard me say, 'mortor, shut, assist.' The first word after Number 1 that I said was 'mortar1 and ap­ pears in the first group of four words. The second group of four words of Number 1, and the third word 'assist1 appears in the third group of four words of Number 1. Your response is to draw a line through the word you hear, making one mark in each group of four words. Erasures are permitted. Are there any questions? (Pause) Each speaker will read nine groups of three words. Remember, draw a line throupdi the word you hear, or think you hear, but always make a response (Black, 1957, p. 234). In administering the second task, the same stimuli and same order for presenting stimuli to the three groups of 26 listeners were used when the seven-point rating scale of intelligibility was administered. The judges were told to employ a seven-point rating scale of intelligibility to each line of words of a word list, i.e. mortar, shut, assist may have a rating of four. These .judges who had listened to the first tape also listened to the second tape and carried out the above task.

The following instructions, were given to the listeners:

Please look at your answer form. You are going to hear a series of groups of three words. Prom your responses we can measure both the intelligibility of the individuals who read the words and your efficiency as a listener in the communication situa­ tion. You will hear: 'I am Speaker 10. I say again, I am Speaker 10. Number 1 mortar, shut, assist.' Your task is to rate the intelligibility of those three words on a seven-point rating scale, 1 being the least intelligible or understandable and 7 being the most intelligible or understandable. There are nine groups of three words for each list. You are to rate each group of three words on this seven-point rating scale of intelligibility. Are there any questions? (Pause) If not, prepare to listen.

Recording the Data

The experimental data, scores on the Multiple-Choice

Intelligibility Tests, were obtained from the judgments made by the 30 listeners on the two listening tasks, the

Multiple-Choice Intelligibility Tests (Appendix A) and the seven-point rating scale of intelligibility (Appendix B).

These panels of judges vrere as follows: (1) experienced with laryngectomized speech rehabilitation, (2) experienced but not with laryngectomized speech rehabilitation, and

(3) naive listeners. The experimental stimuli, 2b lists from Black's Multiple-Choice Intelligibility Tests, were presented to all listeners. A total of 30 listeners (ten from each of the three different panels) responded to the two intelligibility tests employed in this investigation.

The listeners were first given the Multiple-Choice Intelli­ gibility Tests. Second, they were presented the same stim­ uli and told to rate each line of the list of words on a seven-point rating scale of intelligibility: 1 being the least intelligible and 2 being the most intelligible.

Summary

In Chapter III, the experimental speakers, selection of listeners, recording procedures, and the recording of the data were presented. The analyses of the data and results will be stated in Chapter IV, after which the summary and conclusions will follow in Chapter V. CHAPTER IV

RESULTS AND DISCUSSION

This study was designed to investigate the intelli­ gibility of seven methods of producing alaryngeal speech as evaluated by three groups of judges on two listening tasks.

The null hypotheses, statistical treatment, analyses of data, results and discussion are included in this chapter.

The Null Hypotheses

The following null hypotheses were formulated for testing: 1. There is no difference among the seven groups of alaryngeal speakers (the Asai technique, esophageal speech, the Tait Oral Vibrator, the Cooper-Rand Artificial Speech Aid, the Super Aurex Electrolarynx, the Western Electric

Vibrator Type #5, and the Western Electric Pneumatic Reed Type #2A) on the scores for the Multiple-Choice Intelli­ gibility Tests. 2. There is no difference among the three groups of listeners in scoring intelligibility of alaryngeal speech based upon the iMultiple-Choice Intelligibility Tests.

26 3. There is no difference among the seven groups of alaryngeal speakers (the Asai technique, esophageal speech, the Tait Oral Vibrator, the Cooper-Rand Artificial Speech Aid, the Super Aurex Vibrator, the Western Electric Vibrator Type

#5, and the Western Electric Pneumatic Reed Type #2A) on ratings (seven-point) of intelligibility based on words spoken from the Multiple-Choice Intelligibility Tests. 4. There is no difference among the three groups of listeners in rating intelligibility of alaryngeal speech based on words spoken from the Multiple-Choice Intelli­ gibility Tests. 5. There is no. relationship between the scores ob­ tained from the Multiple-Choice Intelligibility Tests and the ratings (seven-point) of intelligibility based on words spoken from the Multiple-Choice Intelligibility Tests for the 28 alaryngeal speakers.

Statistical Treatment

The data were obtained from each of the two listening tasks. A Lindquist Type I Analysis of Variance (Lindquist,

1953) was computed for Hypotheses One through Four. Following the analysis of variance, the individual treat­ ment differences were analyzed by the Newman-Keuls (Winer,

1962) critical difference test. Pearson Product Moment Correlations and a Spearman Rank-Order Correlation (Bruning,

1968) were computed for Hypothesis Five for each treatment 30 on scores obtained from the Multiple-Choice Intelligibility

Tests and the ratings of intelligibility based upon the same tests to determine whether a relationship existed.

Analyses of Data

Intelligibility of Seven Types of Alaryngeal Speech

The first and third hypotheses were concerned with the intelligibility of seven typse of alaryngeal speech based on the scores obtained on the Multiple-Choice Intelligibility

Tests. Hypothesis One, that there is no difference among seven groups of alaryngeal speakers (the Asai technique, esophageal speech, the Tait Oral Vibrator, the Cooper-Rand Artificial Speech Aid, the Super Aurex Vibrator, the Western Electric

Vibrator Type #5, and the Western Electric Pneumatic Reed

Type #2A for the scores based on the Multiple-Choice Intelli­ gibility Tests, was rejected (Table III). In comparing the intelligibility of the seven methods of producing alaryngeal speech, it was found that significant differences existed among the alaryngeal speakers using the various methods

(P=136.7 with 2.80 needed for significance at .01 level). Hypothesis Three, that there is no difference among seven groups of alaryngeal speakers (the Asai technique, esophageal speech, the Tait Oral Vibrator, the Cooper-Rand Artificial Speech Aid, the Super Aurex Vibrator, the Western 31 Electric Vibrator Type #5» ancl the Western Electric Pneu­ matic Reed Type #2A) on the ratings (seven-point) of intelli­ gibility based on words spoken from the Ilultiple-Choice

Intelligibility Tests, was rejected (Table IV). In com­ paring the intelligibility of the seven types of alaryngeal

speech, it was found that significant differences existed among the methods (F=sl95»10 with 2.80 needed for signifi­ cance at .01 level).

Differences Among Groups of Listeners

The second and fourth hypotheses were concerned with the differences among three groups of listeners in their perceptions of intelligibility of the various types of alaryngeal speakers.

Hypothesis Two, that there is no difference among the three groups of listeners in scoring intelligibility of alaryngeal speech based upon the Multiple-Choice Intelli­ gibility Tests, failed to be rejected (Table III). In com­ paring the intelligibility scores from the Multiple-Choice

Intelligibility Tests for the three groups of listeners, it was found that no significant differences existed among the groups (F=.6JP with 5*^9 needed for significance at .01 level). Hypothesis Four, that there is no difference among the three groups of listeners in rating intelligibility of alaryngeal speech based upon a seven-point rating scale of intelligibility, failed to be rejected (Table IV). In com' paring the intelligibility ratings for the three groups of listeners, it was found that no significant differences existed among the groups (P=.?8 with 5*^9 needed for signi' ficance at .01 level). 33

TABLE III

ANALYSIS OP VARIANCE OP THE SCORES OBTAINED PROM THE HULTIPLE-CIIOICE INTELLIGIBILITY TESTS AS JUDGED BY THREE GROUPS OF LISTENERS.

Source SS df MS F

Total 1705.9« 209 _ — b Between Subjects 435*74- 29 Groups 19* 9b 2 99*9 .64 Error 416.76 27 15.44 Within Subjects 1269.24 180

Treatments 104-1.69 6 173*82 136.7*

T x G 21.4-2 12 1.79 1.4-1 Error(W ) 206.13 162 1.27

F = MSG/MSerror (b) P .01 — 5*4-9 (df 2,27) F = KST/MSerror (w) P .01 - 2.BO (df 6,162)

F = MSTxG/MSerror (w) P .01 - 2.IB (df 12,162)

^Lindquist, E. P., Design and Analysis of Experiments in Psychology and. Education,' Boston': Houghton Mifflin Co.’,' pp. 267-273, 1953* 34-

t a b l e IV

ANALYSIS 0? VARIANCE OF THE RATINGS (SEVEN-POINT) BASED UPON WORDS SPOKEN FROM THE MULTIPLE-CHOICE INTELLIGIBILITY TESTS AS JUDGED BY THREE GROUPS OF LISTENERS.

Source SS df F

Total 335-67 209

Between Subjects 65-39 29 --- oc Groups 3.61 2 1.80 •

Error 61.78 27 2.28 Within Subjects 270.2b 180 ---

Treatments 234-. 21 6 39.03 195.10* T x G 2.60 12 .21 1.05

Error(w ) 33.4-7 162 .20

F = HSG/MSerror (b) F .01 - 5.4-9 (df 2,27)

F = MS^/MSerror (^) P .01 - 2.80 (df 6,162) P — M S err or (w) £ .01 — 2.18 (df 12,162) -

^Lindquist, E. F., Design and Analysis of Experiments in Psychology and Education. Boston: Houghton Mifflin Co., pp. 267-273, 1953. 35 In an attempt to determine whether differences existed between (Table III) treatments (methods of alaryngeal speech) of the scores based on words spoken from the Hultiple-Choice

Intelligibility Tests, a Newman-Keuls critical difference test was administered (Table V). The results obtained indi­ cated that the speech produced by the Asai technique was significantly more intelligible than the speech produced by other types of alaryngeal speech. Esophageal speech was significantly more intelligible than the speech produced by all types of alaryngeal speech except the Asai technique. The speech produced by the Super Aurex Electrolarynx was not significantly more intelligible than the speech pro­ duced by the Cooper-Rand Artificial Speech Aid, but it was significantly more intelligible than the speech produced by the Tait Oral Vibraotr, the Western Electric Pneumatic Reed

Type #2A, and the Western Electric Vibrator Type #5. The speech produced by the Cooper-Rand Artificial Speech Aid was significantly more intelligible than the speech produced by the Tait Oral Vibrator and the Western Electric Vibrator Type #5, but it was not significantly more intelligible than the speech produced by the Western Electric Pneumatic Reed

Type #2A. The speech produced by the Tait Oral Vibrator was signi­ ficantly more intelligible than the speech produced by the

Western Electric Vibrator Type #5> hut it was not signifi­ cantly more intelligible than the speech produced by the 36 Western Electric Pneumatic Reed Type #2A. The intelligi­ bility of the speech produced by the Western Electric Pneu­ matic Reed Type #2A was significantly more intelligible than the speech produced by the Western Electric Vibrator Type #5* 37

TABLE V

CRITICAL DIFFERENCE TEST1 PERFORMED ON THE SCORES OF THE SEVEN TYPES OF ALARYNGEAL SPEECH (TREATMENTS) BASED ON THE WORDS SPOKEN FROM THE MULTIPLE-CHOICE INTELLIGIBILITY TESTS.

/F G c D E 3 A

F — 3 4.7 35.7 59.8 72.2 135-5 211.6 * * * it

G 1.0 25.1 37.5 100.8 176.9 * it it

C — 24.1 36.5 99.8 175.9 it ■it «■ it

D --- 12.4 75.7 151.8 * •X-

E --- 63-3 139.4 * it

B --- 76.1 it

A ---

"Significant difference - The horizontal row greater than the vertical column / P - Western Electric Vibrator, Type #5 G - Western Electric Pneumatic Reed, Type #2A C - Tait Oral Vibrator D - Cooper-Rand Artificial Speech Aid E - Super Aurex Electrolarynx B - Esophageal Speech A - Asai

llliner, Ben J., Statistical Principles in Experimental Design. New York: McGraw-Hill, pp. 80-857 19o2. 38

TABLE VI

CRITICAL DIFFERENCE TEST PERFORMED ON THE RATING OF SEVEN TYPES OF ALARYNGEAL SPEECH (TREATMENTS) BASED ON WORDS SPOKEN FROM THE MULTIPLE-CHOICE INTELLIGIBILITY TESTS.

/G C F D E B A

G 13.7 14.4 23.4 26.4 83.0 84.1 * •5c * ■K- •5*

C — .7 10.4 12.7 69.3 70.4 % ■5c •K-

F 9.0 21.0 68.6 69.7 t # *

D --- 3.0 59.6 60.7 •*

E 56.6 57.7

B --- 1.1

A ---

^Significant difference - The horizontal row greater than the vertical column

/F - Western Electric Vibrator, Type #5 G - Western Electric Pneumatic Reed, Type #2A C - Tait Oral Vibrator D - Cooper-Rand Artificial Speech Aid E - Super Aurex Electrolarynx B - Esophageal Speech A - Asai

%iner, Ben J., Statistical Principles in Experimental Design. New York: McC-raw-Hili, pp. 80-85, 19^2. In an attempt to determine whether differences existed

between (Table IV) treatments (methods of alaryngeal speech)

of the ratings based on words spoken from the Multiple-Choice

Intelligibility Tests, a Hewman-ICeuls critical difference test was administered (Table VI). The results obtained indi­ cated that the speech produced by the Asai procedure, with

the exception of esophageal speech, was significantly more intelligible than speech produced by all other types of

alaryngeal speech. Esophageal speech was significantly more

intelligible than the speech produced by the Super Aurex

Electrolarynx, the Cooper-Hand Artificial Speech Aid, the Western Electric Vibrator Type #5, the Tait Oral Vibrator,

and the Western Electric Pneumatic Heed Type #2A.

Speech produced by the Super Aurex Electrolarynx was not significantly more intelligible than the speech produced by

the Cooper-Hand Artificial Speech Aid, but it was signifi­

cantly more intelligible than the speech produced by the Western Electric Vibrator Type #5, the Tait Oral Vibrator,

and the Western Electric Pneumatic Reed Type #2A. The speech produced by the Cooper-Hand Artificial Speech Aid was signi­

ficantly more intelligible than the Western Electric Vibrator

Type #5, the Tait Oral Vibrator, and the Western Electric Pneumatic Heed Type #2A.

The speech produced by the Western Electric Vibrator

Type #5 was significantly more intelligible than the speech produced by the V/estern Electric Pneumatic Reed Type #2A, but 40 it was not significantly more intelligible than the Tait Oral

Vibrator. The intelligibility of the Tait Oral Vibrator was significantly more intelligible than the speech produced by the Western Electric Pneumatic Heed Type #2A.

Relationships Between Scores and Ratings of Intelligibility

The fifth hypothesis was concerned with the relation­ ships between scores obtained from the Multiple-Choice

Intelligibility Tests and ratings of intelligibility based on words spoken from the same test for each type of alaryn­ geal speech.

Hypothesis Five. There is no relationship between the scores obtained from the Multiple-Choice Intelligibility

Tests and the ratings (seven-point) of intelligibility based on words spoken from the Multiple-Choice Intelligibility Tests for the 28 alaryngeal speakers. In comparing the relationships of the two listening tasks for the 28 speakers, the results indicated that a significant relationship existed between the tasks. Therefore, Hypotheses Five was rejected (r = .84)

A Spearman Rank order correlation was performed on the seven types of alaryngeal speech. The results of the statistic yielded a coefficient of .86. This would indicate that when all data were combined and types of alaryngeal speech ranked a significant relationship between the two listening tasks was found at the .01 level. Summary

The null hypotheses, statistical analyses, resluts, and discussion vrere presented in this chapter. The summary and conclusions of this study and the implications for further study will be reported in Chapter V. CHAPTER V

SUMMARY AND CONCLUSIONS

The purpose of this study was to investigate the intelli­ gibility of seven types of alaryngeal speech as evaluated by three panels of listeners. Twenty-eight laryngectomized sub­ jects from Central Ohio each read a list from Black’s

Multiple-Choice Intelligibility Tests. This stimuli was reproduced on a Roberts 7 7 0 X tape recorder. Three panels of ten judges each ranged from experienced speech therapists to naive listeners. The judges performed two listening tasks:

(1) Black's Multiple-Choice Intelligibility Tests, and (2) a seven-point rating scale of intelligibility based on words spoken from the Multiple-Choice Intelligibility Tests, 1 representing the least intelligible and 2 representing the most intelligible speech.

The Null Hypotheses

1. There is no difference among the seven groups of alaryngeal speakers (the Asai technique, esophageal speech, the Tait Oral Vibrator, the Cooper-Rand Artificial Speech Aid, the Super Aurex Electrolarynx, the Western Electric Vibrator Type #5, and the Western Electric Pneumatic Reed

42 43 Type #2A) on the scores for the Multiple-Choice Intelligi­

bility Tests.

2. There is no difference among the three groups of

listeiiers in scoring intelligibility of alaryngeal speech

based upon the Multiple-Choice Intelligibility Tests.

3. There is no difference among the seven groups of

alaryngeal speakers (the Asai technique, esophageal speech,

the Tait Oral Vibrator, the Cooper-Rand Artificial Speech Aid,

the- Super Aurex Vibrator, the Western Electric Vibrator Type

#5» and. the Western Electric Pneumatic Reed Type #2A) on

ratings (seven-point) of intelligibility based on words spoken from the Multiple-Choice Intelligibility Tests. 4. There is no difference among the three groups of listeners in rating intelligibility of alaryngeal speech

based on words spoken from the Multiple-Choice Intelligi­

bility Tests. 5 . There is no relationship between the scores obtained

from the Multiple-Choice Intelligibility Tests and the ratings (seven-point) of intelligibility based on words

spoken from the Multiple-Choice Intelligibility Tests for the

2b alaryngeal speakers.

Results

The results from the analysis of variance indicated that the three groups of listeners did not score differently on the stimuli from the Multiple-Choice Intelligibility Tests.

t 44

Significant differences in intelligibility, however, on the same stimuli existed among the seven methods of alaryngeal speech. A critical difference test was performed on the seven methods of alaryngeal speech. The following results occurred:

1. Asai speech was scored as more intelligible than the other forms of alaryngeal speech. 2. Esophageal speech was more intelligible than speech produced with artificial devices. 3. Of the artificial larynxes, the Super Aurex Electro­ larynx was more intelligible than the Tait Oral Vibrator, the

Western Electric artificial larynxes Types #2A and #5.

4-. The Cooper-Hand Artificial Speech Aid was more intelligible than the Tait Oral Vibrator and the Western Electric Vibrator Type #5.

5. The Tait Oral Vibrator was more intelligible than the Western Electric Vibrator Type #5.

6. The Western Electric Pneumatic Heed Type #2A was more intelligilbe than the Western Electric Vibrator Type #5* The results from the analysis of variance indicated that the three groups of listeners did not rate the stimuli dif­ ferently when using the seven-point rating scale of intelli­ gibility. Significant differences in intelligibility existed among the seven methods of alaryngeal speech. A critical difference test performed on the seven methods of alaryngeal speech indicated that: 45 1. Asai speech was rated as more intelligible than

speech produced by the five artificial larynxes employed in

this study. The treatment total (sum of ratings) of Asai speech was higher than the treatment total (sum of ratings) of esophageal speech; however, this difference was not signi­

ficant.

2. Esophageal speech was rated as more intelligible than the speech of speakers using five artificial devices employed in this study.

3. The Super Aurex Electrolarynx was rated as more intelligible than the Western Electric Vibrator Type #5, the

Tait Oral Vibrator, and the Western Electric Pneumatic Reed

Type #2A.

4. The Cooper-Rand Artificial Speech Aid was rated as more intelligible than the Western Electric Vibrator Type

#5, the Tait Oral Vibrator, and the Western Electric Pneu­ matic Reed Type #2A.

5. The Western Electric Vibrator Type #5, was rated as more intelligible than the Western Electric Pneumatic Reed

Type //2A. b . The Tait Oral Vibrator was rated as more intelli­ gible than the Western Electric Pneumatic Reed Type #2A. The results from the correlation between the intelligi­

bility scores on the Multiple-Choice Intelligibility Tests and the ratings of intelligibility for 28 alaryngeal

speakers, revealed a relationship for intelligibility existing ^6

between the two listening tasks.

The data from the 28 alaryngeal speakers were combined and a rank order correlation performed. The results indi­

cated that the speakers' scores, as judged by 30 listeners,

on words spoken from the Multiple-Choice Intelligibility

Tests, were predictive of how the types of alaryngeal speech would be ranked on the two listening tasks.

Conclusions

The three groups of judges with various levels of experience in speech rehabilitation of laryngectomized patients did not differ on their scorings and ratings of alaryngeal speakers for the two listening tasks.

Significant differences appeared among the seven types of alaryngeal speech for the intelligibility scores and ratings obtained on the Multiple-Choice Intelligibility

Tests. Speech produced by Asai speakers was more intelli­ gible than the alaryngeal speech produced by the other methods, including esophageal speech. Esophageal speech was more intelligible than the speech produced by the artifi­ cial larynxes. The Super Aurex Electrolarynx and the Cooper-Rand Artificial Speech Aid were the most intelligi­ ble artificial larynxes. The relationship between the scores of the Multiple-

Choice Intelligibility Tests and the ratings of the seven- point rating scale of intelligibility revealed a correlation of .84. This indicated that the scores assigned to the 28 alaryngeal speakers on the Multiple-Choice Intelligibility Tests were predictive of how they v/ould perform when a seven-point rating scale was applied to the same stimuli. The rank order correlation suggested that, of the seven types of alaryngeal speech, Asai speech ranked highest on both of the listening tasks; esophageal speech was the next highest.

Implications for Further Investigation

Further studies to evaluate and compare the values of

Asai speech are indicated. Suggestions for such research include studies of (a) the production of phonation in the

Asai speaker as compared with that of the esophageal speaker,

(b) the digital manipulation of the dermal tube and its effects on voice quality, (c) the on loud­ ness in the improvement of Asai speech, and (d) cinefluoro- graphic measurements of Asai speech to determine the pattern of movement of the dermal tube. BIBLIOGRAPHY

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Magulies, Vivian, "Teaching Speech to Laryngectomees," New York,State Journal of Medicine, pp. 2954-2957, 1965. Martin, Hayes, "Esophageal Speech," Annals of Otology. Rhinology. and Laryngology. 59:637-690, 1950.

Martin, Kayes, "The Incidence of Total and Partial Laryn­ gectomy, 1947 and 1952," Cancer. 3:1122-1125, 1955. Martin, Hayes, "Rehabilitation of the Laryngectomee," Cancer. 16:323-341, 1963.

McCroskey, Robert L. and Hariene Mulligan, "The Relative Intelligibility of Esophageal Speech and Artificial- larynx Speech," Journal of Speech and Hearing Dis­ orders. 23:37-41, 1963.

Miller, Alden K., "First Experiences with the Asai Technique for Vocal Rehabilitation after Laryngectomy, Annals of Otolaryngology. 76:329-333, 1967. 52 Hiller, Alien II., "Further Experiences with the Asai Tech­ nique of Vocal Rehabilitation after Laryngectomy," Transactions of American Academy of Opthaiology and Otology. 72:779-781, 1968. Hiller, George A., "The Magical Humber Seven, Plus or Minus Two: Some Limits on our Capacity for Processing Information," The Psychological Review. 63:81-97, 1956.

Miller, Maurice K., "The Responsibility of the Speech Therapist to the Laryngectomized Patient, Archives of Otolaryngology. 70:211-216, 1956. Montgomery, William V/., "Voice Rehabilitation after Laryn­ gectomy, " Archives of Otolaryngology. 68, 1968.

Moolenaar-Biji, A., "The Importance of Certain Consonants in Esophageal Voice after Laryngectomy," Annals of Oto­ laryngology. Rhinology. and Laryngology. 52:979-989, 1953. Morrison, W. Wallace, "The Production of Voice and Speech Following Total Laryngectomy," Archives of Otolaryn­ gology, 14-: 413-431, 1931. : Hilo, Ernest Ricard, "A Comparative Study of the Low Fre­ quency Characteristics of Certain produced by Laryngectomized and Hormal Speakers," Unpublished Master's Thesis, University of Maryland, 1957. Porres, R. and V. F. Herson, "Tracheopharyngeal Shunt After Total Laryngectomy," Archives of Otolar?/ngology. 88: 37-41, 1963. Schuler, Verna Jean, "Factors Predicting Comprehensibility of Esophageal Speech," Unpublished Master's Thesis, The Ohio State University, 1967.

Serafini, I., "Restoration of Laryngeal Function After Laryngectomy Experimental Research in Animals,” Advances in Oto-Rhino-Laryngology. 16:95-122, 1969.

Shames, George H., John Font, and Jack Matthews, "Factors Related to Speech Proficiency of the Laryngectomized,M J ournal of Speech and Hearing Disorders. 28:273-287, 1963. Shanks, James C., "Advantages in the Use of Esophageal Speech by a Laryngectomee," The Laryngoscope. 76:239-243, 1966. 53 Shumrick, Donald A., "Supraglottic Laryngectomy," Archives of Otolaryngology. 89:629-635, 1909. Snidecor, John C., Speech Hehabilitation of the Laryngec- tomized. 2nd ed., Springfield, Illinois: Charles C. T h o m a s 1908. Snidecor, John C., and E. Thayer Curry, "How Effectively Can a Laryngectomee Expect to Speak? Norms for Effective Esophageal Speech," The Laryngoscope. 70:02067, 1060.

St. Clair Thomson, "History of Cancer of the Larynx," J ournal of Laryngology and Otology. 54:61-87, 1939.

Vrticka, K. and II. Svoboda, "A Clinical and X-ray Study of 100 Laryngectomized Speakers," Folia Phoniatrica. 13: 174-186, 1961.

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Wallen, Vincent, "Rehabilitation of the Laryngectomy Fatient," Military Medicine. 131:137-144, 1966.

Wetman, Joseph M., John A. HacGahara, Joseph C. Rickard and Neal W. Shelton, "Objective Measurement of Progressive Esophageal Speech Development," Journal of Speech and Hearing Disorders. 18:247-251, 1953* Winer, Ben J., Statistical Principles in Experimental Design. New York: McGraw-Hill, pp. 80-&5, 1962.

Yen.. Chen, Li-Ching Yen, Harry Samberg and Bernard Felsen- stein, "Aspects of Rehabilitation of the Laryngectomized Patient," Archives of Physical Medicine and Rehabili­ tation. 4472^7-272, 19^37“ APPENDICES APPENDIX A 55

- m z ~ z Speikcr it I Ur » Speaker 18 la J ) . - 1 < 2 l I bam o Speaker 10 It Spcaker 11 It . 4?ij£azr] I (ami v vesper knoll sum m er m an ’•bun arm artist bun a % harness fester known 1 summon mass fun sum m er m an I sum m it mask front summon mass fun u n ttalnada 1 harvest pester no lnsant a festive mold summons mad fund summit m ask front orchid summons mad fund 2unaaan I bomb Boston lighter roller none I uni tain a simple roller none 3 sinful bound frosty 3 spider rolling mountain tighter frosting Zm fighter roll now spider rolling mountain I vawal ^ summon bond now bow stomach barn cross piker ro a r num b tighter roll piker roar numb 3 vow litter w restle pope verbal breeze eat burble greed heat verbal breeze eat valva 3 little rascal hope 3 ■pouaa « rapture oak 3 gurgle breathe feet burble greed heat 3 glitter feet aitound < liquor raffle post purple grieve peak gurgle breathe purple grieve peak 4 tipouaa 1 main tw elve march fried plus child aapouaad 1 fried plus child m mink welt m argin A lry flood childish m arching ^ tribe bust childless try flood childish tonfua 1 make wealth childless h u m i m ate tw elfth M artin tried pluck childhood tribe bust tried pluck childhood 5hum i lengthen geese ram we retold guess ton i p ointm ent east wing r read refold guest we retold guess green 3 weed threefold gas read refold guest W«t 3 Lincoln meat w ait link yeast ring weave repose get weed threefold gas weave repose le t 6 wept bud rough hearing sofa hate best weapon drunk hairy £ soap cape bet sofa hate best £ bus author O bust rum p carry O silver cake desk soap cape bet but rum herring sober case theft silver cake desk otter sober case theft often pleasant widen saint lung h u rt pardon office m pheasant wide safe 3 love turn hardly lung hurt pardon ; / peasant wife faint / drunk turf harden love turn hardly prune present wagon sink lump Turk hard drunk turf harden \ c ru d e ' lump Turk hard true w inter model log shilling falcon m ark prove q winner m arvel lawn q chilling pulpit mock shilling falcon m ark Q where marveiou<> blond g chilly culprit lock chilling pulpit mock (uie woman m arble long killing poker mop chilly culprit lock feud killing poker mop hue lose itself mash gag nap allow tew O loose excel gnash Q *»

£ L prater II Speaker 8 Is ' ^ ur*e Speaker »U C " W./}, Speaker 11 Jm C~i S78T" heard eighty trum p irk bile abhor pulse toward feeling dome purge 1 acre front hurt | bike applause fault forge dealer don't courage I aching truck earth 1 vice applaud pulp ford ' fever zone eight trunk heard acallop fight apply false board feeler stone acholar delude head gauge apace runny goose destroy girl flicker 2 acout 3 remove edge gaze *% attain rubbish noose deprive pearl clipper (lU op 2. elude hedge gave £ face ready use 2 defraud curled liquor renew bleu egg gey aface ruddy deuce defrost curl quicker leu can ! arm flatter bruise by rather chart frightful sultry 3 left 3 scant armed clim ate 3 brood spy letter short rifle culprit 10 lait 3 scamp on planet 3 brew fire lever shark greattul sculpture scan odd bridge plant cruise five leather sharp rightful sculptor 11 i rich find purse fitness bramble love hence native pearl calf fridge m bind burst thickness s scramble mark tense navy crow cad rig vine hurt sickness *1 gravel large tent naked throw calves 12 fine first picnic ram ble lark hint nature grow cab even beacon dum b bedroom royal stain patron train tathe candy ink 5deacon C gum reverend broil r stink patient crane lay pantry pinch 1 deepen j dump brother broiled 3 sting hasten brain laid pansy inch done brethern boil sing paper frame leg handy hint | aettle aubtle snout wide afford groom cub listen thus legend hit * smelt 5 eettled why abhor £ prune tug christen bust ledger fist •even 3 snub wise accord O broom tough Christm as duck leaden this snap ride afore room tub prison dust lesson kiss hung hum stead price bury handsomeparcel fear bulb cut net m dead i bulge carpet met 7tongue Christ barely *» cancer hardly peer coma / sped fight fairly / cam phor partly hear bald cotton neck bed strike fairy cancel parsley tear bait copper nest meage maker white gown error suit cotton neither breast Capital glass Q poison down errand m eter friend hapless lad 8m eter q soon coffin eager O hoist gam barren O soothe coffee meager breath hatlcss blast voice gauze Arab sue copy leader bread happen black caugh next racket drab steam hum p exalt harbor soft hood talk harder sought could 9 taugh Q nets blacken draft O seen hunt result trougl s mix blackened graft 7 speed pump gulf ai dor salt put neck black grab esteem punk exhaust artist sulk K«MMt 55

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f it y SpeakeiSpeSCin i S crash Speaker 3 Is C "* / L.fi, Speaker • la C 7.J T-./t- Speak U m c s , p . drag apply gift lamp needle large haven trash bite abhor pulse thrasti | supply if lance | bike applause fault evil lodge heaven 1 amply hit glance 1 vice applaud pulp Imeal lie even pillow ny it land fight apply false neither live able pillar bust handle free dimple interest cast 2 killer apace runny goose filler fuss anvil freeze 2 attain rubbish noose « gentle penguin past ^ but amble freed g, face ready use f, devil hindrance pass la v a bus ample tree aface ruddy deuce dental kindred path loud airy fed laugh bruise by rather armload pen wooden 3 lock 2 hairy stead glad 2 brood spy letter • armholec ten woody robbc 3 arid spend lash 3 brew fire lever ) armhole tend wood g lad carry sped flash cruise five leather arm ful tent witty lad throw low rod bramble love hence gem glaze creeping ■ laugl- A froze rose brown a scram ble m ark tense « gent ' play greeting lag ■ prose loath somebrow gravel large tent f gin blade greedy gym blaze punt* probe lonesome proud ram ble lark hint reading > teach desk stance science st&in patron train Hush size w aitful i tinct C depth stand silent r" stink patient crane • pledge sigh wake p ictu 3 dead stamp sound 3 sting hasten brain ) fresh scythe wasteful flesh side wakeful temp death spent silence sing paper fram e > ten si broke code begun groom cub listen auburn astride dial I ten t £ growth told begot prune tug christen ^ ofteh ascribe guile hem; 0 throat cold forgot 0 broom tough Christmas ) author prescribe vial deduct autum n describe guide y o u t wrote coal room tub prison r y ou sister hulk mild handsome parcel fear nest rug harrow u se ^ system halt mile 2 cancer hardly peer • m esl love herald mut* / cistern pulp miles / cam phor partly hear f meant rough arrow pistol fault mine cancel met rub peril /3 tigh parsley tear » P‘k« strike limp town suit cotton neither g r a in bench nuptial I h eig O spite limb townsman Q soon coffin m eter raise theft nocturnal hike lend townsmen raid fetch nutshell O fight O soothe coffee meager 8 d e v spike lent count sue copy leader rage thatch neptune i Jefj paid cute fell steam hum p exalt flapper stole wallet ' d ivi Q page cunningspell q seen hunt result leopard stone swallow besi / age honey felled / speed pump gulf le p e r school wall haze puny bell esteem punk exhaust le tte r scold wallow Jt, n

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Speaker 14 la . j ) - jig right lay KK- gate brighten blade m ouse drink towel dig frighten blaze i rr juntainbring Holland gig bright glaze 1 m ount brink tallow hallow safer worn lift m outh spring savor one lick q u a rter dove cook favor wand lit •> porter dope approach saber blend lip i. order dough croak dull broke decay gross smile border debate grow th sm art dull detect hinge efface group smock 3 gulf effect tinge deface broke mock i gun deflect pin dog defect wool blast village king woe glad visit effect goat hash wove glass busy a infect scope add low black vivid inspect spoke ask confess stake ash plain room gold playm ate loom go root wash doubtless plainly move dull £ group watch thoughtless plainnessmoon dough J droop why dauntless roof walk darkness rigid lion bit bridges why fit shell try staple frigid wind disc £ chow cry table tribute wine dip O shall fry stable child pry spacious m ortar flood press w arble luck crept sudden front gauze m ortal blunt crest *7 sun punch cause m orbid bluff pressed / seven punt guard southern hunt dog does bend resort bud gem export cuss green razor 8 buzz dim absorb O Put dream raisin bug den exhort O puss greed reason push grieve brazen lesson bud sold glisten bug so talk happy repress blessing buzz seold q toss after depress blessed budge sole y taught happily regret hat athlete request 58

Appendix B

M/HE_____ un: CiROOT* Phone £__ (/) C HJ1,C, ! (2) D-l D.M,N. (3) D E.H. SPEAhEB 10 SPEAKSB ■I 18 SPEAKER V _18 o 1„ 1 2 3*» 4 5 Z 7 1 . 1 2 3 4" o I. . » 5 4 J ? V 4 3 6 7 2 . 1 2 3 4 •; 6 ? 2 < 4 6 7 4 i 2 3 4 5 6 7 ?* 1 2 3 5 6 7 3 4 6 7 4 . l 2 3 4 5 6 7 4 , 1 2 3 4 :5 6 7 J: 3 4 6 7 *>. i 2 3 4 5 6 7 3- 1 2 3 4 3 6 7 C, j i 6 7 6 . l 2 3 4 5 6 7 6™ 1 2 3 4 3 6 7 6* 3 ■j 6 7 7 . l 2 3 4 5 6 7 7 c 1 2 3 4 .5 6 7 ?o 3 4 6 7 8 . l 2 3 4 5 6 7 fi.» 1 2 3 4 5 6 7 e» 3 4 6 7 9 . l 2 3 4 5 6 9» 1 2 3 4 5 6 7 4 o 7 7 1 9. 3 ---- -! <4> c I.t ; <5) 0 M.A -<6) C-l E7B7-- SPEAKER # 8 SPEAKER 'ft 9 SPEAKE8 y? 11 1 , 1 2 3 4 5 6 7 1 O 1 2 3 4 > 6 7 I 2 4 T 2„ 1 2 3 4 5 6 7 2 c 1 2 3 4 5 6 7 2 4 6 3 , 1 2 3 4 5 6 ? 3 c 1 2 3 4 .5 6 7 2 ' 4 6 4 , 1 2 3 4 5 6 ? 4 . 1 2 3 4 5 0 7 2 4 6 5. 1 2 3 4 5 6 7 5 . 1 2 3 4 5 6 7 2 4 6 6 . 1 2 3 4 5 6 7 6 . 1 2 3 4 5 6 7 2 4 6 7c 1 2 3 4 5 6 7 ?. 1 2 3 5 6 7 2 4 6 8 . 1 2 7 4 5 6 7 8 „ 1 2 3 4 5 6 7 2 4 6 9* 1 2 5 4 5 6 7 9* 1 2 3 4 5 6 7 4 6 D-l B.S (8) C A.M.H. (9) D-l B.A. 5Pii.-vKE g 7 SPEAKER 7 SPEAKER # 19 1 . 1 2 3 4 ■5 6 7 1. 1 2 3 4 5 6 7 I , 1 2 3 4 5 & V 2 o 1 2 3 4 5 6 7 2 . 1 2 3 A 5 6 7 2 , 1 2 j 4 5 6 V 3 . 1 2 3 4 5 6 7 J <* J 2 3 t 5 6 7 3. X 2 3 4 5 6 7 4 . 1 2 3 4 ■5 6 7 4 . I 2 3 4 5 6 7 4 , 1 2 3 4 5 6 7 1 2 4 6 y 1 2 4 6 7 I 2 'i 4 6 7 5- 3 5 5° 3 5 5. /■) J 5 6 . 1 2 3 4 5 6 7 6 . ) 2. 3 4 3 6 7 6o 1 A. 3 4 5 6 7 7 . 1 2 3 4 5 6 7 7c 1 2 3 4 5 6 7 7» 1 2 3 4 5 6 8 . 1 2 3 4 5 6 ? 8 . 1 2 3 4 5 6 7 3 , 1 2 '1 4 5 6 7 9 . . 1 2 3 4 5 6 7 9- 1 2 3 4 5 6 7 ?c 1 2 j 4 5 6 7 _. 7 j.. J. 2 3 1;. 5 6 7 I, 1 2 3 4 6 7 • H 2 . 1 2 4 *5 6 7 i 2~ A 2 3 4 5 6 7 2 . 1 2 3 4 5 6 7 3 n 3 . 1 2 3 4 5 6 1 3c 1 2 3 5 6 7 3. 1 2 3 4 5 6 7 4 . 1 2 3 4 5 6 7 ! 4 , 1 2 3 4 5 6 7 4 , 1 2 3 4 5 6 7 5o 1 2 3 4 *5 6 7 1 2 3 /•, 5 6 7 5.. 1 2 ** 4 5 6 7 6 . 1 2 4 £ 6 c 1 2 3 f. s 6 7 6„ 1 2 3 4 5 6 7 3 5 7n 7 ° 1 2 3 4 9 6 7c \ 2 3 4 5 6 7 7« 1 2 3 4 5 6 ? 8 . 1 2 3 4 •3 6 7 8 „ 1 2 3 t 5 6 7 8c 1 2 3 4 5 6 7 9« 1 2 3. 4 5 6 7 9 , 1 2 3 4 5 6 7 9 . 1 2 3 4 5 7 —-*■ ■ f-(iA7 —“T — — (13) C- r -----V.A. -~c=i «*• (157 r s i r SPEAKER g 3 S.“EAKER * 9 SPEAKER # _ « A 1 . 1 2 3 4 9 6 7 1 , .1 2 3 4 6 7 1c 1 2 3 4 5 6 7 2 . 1 2 3 4 3 6 7 a 1 2 3 /. 5 6 7 2 . 1 2 3 4 5 6 7 / 3« 1 2 3 4 5 6 7 ,'lo 1 2 3 4 9 6 7 3c I 2 3 4 5 t/ 4 . ) 2 3 4 3 6 7 (T. .1 2 3 A 5 6 7 .» 1 2 3 4 5 6 / 2 4 6 *> .1 2 4 5 6 7 5c i 2 3 4 5 6 7 5* 1 3 -3 5» 3 G 6 . 1 2 3 4 3 6 ? 6 . I 2 3 4 9 6 7 6c 1 2 3 4 S 6 V 7 . 1 2 3 4 4 6 7 7c 1 2 3 A 5 6 7 7.. 1 2 3 4 5 6 7 8 . 1 2 3 4 A A 7 8 . I 2 3 1. 9 8 7 8c 1 2 3 4 5 6 7 9 . 1 2 3 4 9 6 7 o„ I 2 3 A 5 6 7 9- 1 2 3 4 5 6 7 59

Appendix B NAME PHONE (16) D M.C (17) D J.Hr. (18) D-l D„/., SPEAKER # 24 SPEAKER # 22 SPEAKER if 20 1. 1 2 3 4 ~5 6 7 1. 1 2 3 4 ' 5 "6 7 1. 1 2 3 4 5 6 7 2 . 1 2 3 4 5 6 7 2. 1 2 3 4 5 6 7 2. 1 2 3 4 5 6 7 3 . 1 2 3 4 5 6 7 1 1 2 3 4 5 6 7 3. 1 2 3 4 5 6 7 4 . 1 2 3 4 5 6 7 4 . 1 2 3 4 5 6 7 4 . 1 2 3 i'9 5 6 7 5 . 2 2 3 4 5 6 7 5 . 1 2 3 4 5 6 7 5 . 1 2 3 4 5 6 7 6. 1 2 3 4 5 6 7 6 . 1 2 3 4 5 6 7 6. 1 2 3 4 5 6 7 7. 1 2 3 4 5 6 7 7 . 1 2 3 4 5 6 7 7. 1 2 3 4 5 6 7 8 . 1 2 3 4 5 6 7 8 . 1 2 3 4 5 6 7 8. 1 2 3 4 5 6 7 9 . 1 2 3 4 5 6 7 9 . 1 2 3 4 5 6 7 9. 1 2 3 4 5 6 7

(19) C P.J. (20) D B. P. (21) C D„R. SPEAKER # 5 SPEAKER # 19 SPEAKER # 1 1. 1 2 3 4 5 6 7 1. 1 2 3 4 5 6 7 1. 1 2 3 4 5 6 7 2 . 1 2 3 4 5 6 7 2 . 1 2 3 4 5 6 7 2. 1 2 3 4 5 6 7 3. 1 2 3 4 5 6 7 3. 1 2 3 4 S 6 7 3. 1 2 3 4 5 6 7 4 . 1 2 3 4 5 6 7 4 . 1 2 3 4 5 6 7 4 . 1 2 3 4 e 6 7 5 . 1 2 3 4 5 6 7 5 . 1 2 3 4 5 6 7 5. 1 2 3 4 5 6 7 6. 1 2 3 4 5 6 7 6 . 1 2 3 4 5 6 7 6. 1 2 3 4 5 6 7 7. 1 2 3 4 5 6 7 7 . 1 2 3 4 5 6 7 7. 1 2 3 4 5 6 7 8 . 1 2 3 4 5 6 7 8 . 1 2 3 4 5 6 7 8. 1 2 3 4 5 6 7 9 . 1 2 3 4 5 6 7 9 . 1 2 3 4 5 6 7 9. 1 2 3 4 5 6 7

(22) C-1 C.P, (23) CJ.H. (24) C D.K SPEAKER * 2 SPEAKER # 2 SPEAKER t l i 1. 1 2 3 4 5 6 7 1. 1 2 3 4 5~ ~b 7 1. 1 2 3 4 5 6 7 2 . 1 2 3 4 5 6 7 2 . 1 2 3 4 5 6 7 2 . 1 2 3 4 5 6 7 3. 1 2 3 4 5 6 7 3. 1 2 3 4 5 6 7 3. 1 2 3 4 5 6 7 4 . 1 2 3 4 S 6 7 4 . 1 2 3 4 5 6 7 4 . 1 2 3 4 5 6 7 5 . 1 2 3 4 5 6 7 5 . 1 2 3 4 5 6 7 5 . 1 2 3 4 5 6 7 6 . 1 2 3 4 5 6 7 6. 1 2 3 4 5 6 7 6 . 1 2 3 4 5 6 7 7. 1 2 3 4 5 6 7 7. 1 2 3 4 5 6 7 7 . 1 2 3 4 5 6 7 8. 1 2 3 4 5 6 7 8. 1 2 3 4 5 6 7 8 . 1 2 3 4 5 6 7 9. 1 2 3 4 5 6 7 9 . 1 2 3 4 5 6 7 9 . 1 2 3 4 5 6 7

D'-1 C -l J .P . (26) D- •1 C. B. (27) ( 25) SPEAKER * 22 SPEAKER # 1 SPEAKER 0 14 7 1. 1 2 3 4” 5 “ 6 7 1. 1 2 3 4 5 6 7 1. 1 2 ■ 3 4 5 6 2. 1 2 3 4 S 6 7 2 . 1 2 3 4 5 6 7 2 . 1 2 3 4 5 6 7 3. 1 2 3 4 5 6 7 3. 1 2 3 4 5 6 7 3 . 1 2 3 4 5 6 7 4 . 1 2 3 4 5 6 7 4 . 1 2 3 4 5 6 7 4 . 1 2 3 4 5 6 7 6 7 5. 1 2 3 4 5 6 7 5 . 1 2 3 4 5 6 7 5 . 1 2 3 4 5 7 6. 1 2 3 4 5 6 7 6. 1 2 3 4 5 6 7 6 . 1 2 3 4 5 6 7 7 . 1 2 3 4 5 6 7 7. 1 2 3 4 5 6 7 7 . 1 2 3 4 5 6 7 8. 1 2 3 4 5 6 7 8. 1 2 3 4 5 6 7 8. 1 2 3 4 5 6 6 7 9 . 1 2 3 4 5 6 7 9. 1 2 3 4 5 6 7 9 . 1 2 3 4 5

(28) D K.K. SPEAKER * 14 6. 1 2 3 4 5 6 7 1. 123A567 7 1234567 2. 1234567 . 8. 1234567 3. 1234567 4. 1234567 9. 1234567 5. 1234567