Talking the Talk 

Speech Recognition Information 
For the IBM ViaVoice Enterprise SDK

Preface
This document is intended for marketing representatives and end users who's product solution has embedded the IBM Enterprise ViaVoice SDK.  Its purpose is to provide important speech techniques that will assist a person in obtaining the best recognition accuracy and learning capabilities. 

Table of Contents
Preface
Table of Contents
Trademarks and Service Marks
Overview
Accuracy/Enrollment Hints and Tips
From our FAQ:
When Experiencing Low Accuracy
Enrollment Tips
Dictation Tips
Command Accuracy in Dictation Mode
Pronouncing Numbers, Dates, and Times
Rules for Pronouncing Numbers
Rules for Pronouncing Dates
Rules for Pronouncing Times
Moving enrollment files from one user to another
ViaVoice User Wizard
Audio Setup Wizard
Creating a voice model
Creating Additional Voice Models (Enrollments)
Appendix A
RADIOLOGY SAMPLE #1:
RADIOLOGY SAMPLE #2:
PATHOLOGY SAMPLE #1:
PATHOLOGY SAMPLE #2:
GENERAL MEDICAL SAMPLE #1:
GENERAL MEDICAL SAMPLE #2:

Trademarks and Service Marks

The following trademarks belong to Microsoft Corporation:
COM  ActiveX  Windows  Windows NT   Windows 95    Windows 98   Windows 2000

The following trademarks belong to the IBM Corporation in the United States and/or other countries.             
IBM      MedSpeak/Radiology      VoiceType      ViaVoice98   ViaVoice Millenium

Licensed Materials - Property of IBM
Copyright IBM Corp. 1997, 1998, 1999, 2000 All Rights Reserved.
US Government Users Restricted Rights - Use, duplication or disclosure restricted by GSA ADP Schedule Contract with IBM Corp. 

Overview
Achieving the highest level of accuracy by understanding the correct speech dictation techniques can enhance a product offering that has incorporated the IBM ViaVoice Enterprise SDK component.  This document will assist a user in troubleshooting common speech problems that are associated with low accuracy and speech recognition learning.        

Accuracy/Enrollment Hints and Tips

From our FAQ:

Q.  When do I need to enroll (create a voice model) ?
A1) When the system has a hard time understanding your speech patterns.  It is recommended that each user complete a 50 sentence enrollment.  Speakers with a heavy accent are encouraged to complete the entire enrollment process consisting of the reading of 200 sentences.

A2) When you dictate in very different environments (e.g. one noisy, another very quiet), it is recommended that you first determine if there is an accuracy degradation in a particular environment.  If so, you should create a new enrollment for that environment.

A3) When you switch to another microphone, e.g. from a hand held to a headset, it is important to have an enrollment for each one.  

A4) When you switch soundcards, it is important to have an enrollment for each one.  
 
When Experiencing Low Accuracy

NOTE Please retest for accuracy after performing each of the following “tests”:

1.   Check that the microphone is plugged into the correct jack in the sound card.  Computer cases can conceal part of the sound cards labeled jacks.  This is a common mistake, so it is worth double-checking.
2.   Check that the microphone is plugged into the sound card tightly.
3.   Check to make sure both ends of the microphone cable are screwed together tightly.
4.   Make sure the microphone cable has not been run between power sources, (e.g., between a monitor and CPU) since these power sources have been known to cause electrical interference.
5.   Test the sound card with the operating system sound recorder by recording with a microphone attached, specifically listening to the playback for the quality of "silence".
6.   Check that the sound card is using the appropriate sound driver.
7.   Try reseating the sound card in a different slot inside the computer.  It is recommended that the placement be away from the fan and network card. 
8.   Listen to the playback of the text for static or buzzing.
•	If either occurs, try dictating further away from electrical components, (e.g., monitor and speakers).  You may also try installing a surge protector with noise filtering capabilities such as an RFI and/or EMI filters to eliminate outside interference.
9.   Check the volume level while dictating to ensure it is in the green.  
10. Check that the microphone is being used properly.
•	With the hand held, speak down the long axis with your mouth.
•	With the head set, position the microphone boom about 3/4 inch away from the corner of the mouth.  The microphone pad acts as a windshield (Helps prevent your breathing from being recorded, so make sure it is in place).  The pad usually is a foam ball placed on the microphone.  You will notice lower accuracy without it.
11. Listen to the playback of the text for clear pronunciation of words that were “recognized” incorrectly. *
12. If you are using the default enrollment, enroll the first 50 sentences and train.
13. If you are enrolled, check Enrollment Tips below to ensure the enrollment was created properly and is being used correctly.
14. If you are enrolled, try testing accuracy with an untrained enrollment or create a new enrollment while double checking Enrollment Tips.

*   Before correcting the dictation, listen to the playback for clarity of sound, clear pronunciation, and additional noise. If there are problems with the sound, follow Enrollment Tips to help solve the problem.  If there are additional noises, try to re-dictate (if excessive noise is “normal”, please enroll in this environment and use this new enrollment at this workstation).

Enrollment Tips

•	Make sure the enrolling user selects the unique user id assigned to them.  Also, make sure the correct enroll id (voice model) to be enrolled under is chosen
•	Do a 50-sentence enrollment first.  If necessary, complete the remaining 150 sentences (this has produced better recognition than enrolling and training 200 sentences right away).
•	While dictating an enrollment sentence, make sure the user talks in his/her normal dictation voice and dictates the enrollment at the speed of normal dictation.  Dictating slowly or with pauses can degrade accuracy.
•	When creating a new enrollment (voice model), make sure the enrollment environment is the same as the dictating environment (e.g., a noisy dictating environment would require an enrollment done in a similarly noisy environment).
•	Use the same equipment, e.g. computer, sound card, and microphone, for enrollment that will be used for dictation.
•	In enrollment, check the audio level and make sure it is in the green during dictation.  Enrolling while audio levels are red or yellow can degrade the accuracy.  To adjust the audio level, the user can adjust their speaking volume, the microphone distance, or the operating system volume control (the volume control is preferred).
•	While dictating enrollment sentences, you notice that you misspoke a word, re-record that sentence, or if the sentence was accepted, go back to the previous sentence and re-record it.
•	Make sure the enrollment has trained successfully.  Please check with your developer/vendor for steps on how to do this.
•	Make sure to log into the product with the trained enrollment.  Please check with your developer/vendor for steps on how to do this.

Dictation Tips

•	Make sure the audio level is in the green. Some speakers have found the lower level of green gives them better accuracy than the higher level of green, and vice versa.  This is something that will require testing on the user’s part to determine.
•	Hand Held: Make sure user speaks down the long axis of the hand held microphone, not across the top.
•	Hand Held: Make sure the user does not rest their mouth on the top of the microphone, about 1-2 inches away is the correct position.
•	Headset: Make sure the user has the boom portion of the microphone 3/4 inch from the corner of the mouth (approximately 2 finger widths), and not directly in front of the mouth.
•	Make sure the words not recognized were enunciated clearly and not slurred together.
•	Listen to the playback of the text, if you hear noise, buzzing, or other non-environment noise, check the card and the location of the microphone (relative to the speakers, monitor, or other electrical components).  Test recording at different distances from these components to see if the playback noise is reduced or eliminated.
•	If there is non-environment noise in the playback, move the sound card into a different slot away from other cards and fans inside the casing.  If noise persists, contact your hardware support specialist.
Command Accuracy in Dictation Mode

To ensure commands are recognized during dictation (and not taken as dictated text), the speaker (user) MUST distinctly pause (approximately 1/2-second) between dictating text and speaking a command.   For example, when a user completes their dictation, they must pause before saying "End-Dictation" or "Stop-Dictation".  Otherwise, these commands will be taken as dictated text and the system will continue to listen for more input.  

Pronouncing Numbers, Dates, and Times
Rules for Pronouncing Numbers
1.	Dictate numbers using single or pairs of digits.
2.	“Zero” or “oh” are interchangeable except for leading 0’s, when you must use “zero”.
3.	Non-integers are dictated by using the above rules to dictate the digits to the left of the decimal point, then saying the word “point”.  Use rule 1 above to dictate the digits to the right of the decimal point.
4.	Negative numbers are dictated by saying:  “negative”, “minus”, or “minus-sign” and then the number as stated above.

Examples
Note:  There should be no pauses within quoted phrases.  Pauses in between quoted phrases should not degrade the accuracy.

For the number		Say
5			“five”	

23			“two” “three”, or
“Twenty-three”

345			“three” “four” “five”, or
“three” “forty-five”, or
“three” “hundred-forty-five”, or
“three” “hundred-and-forty-five”

1234			“one” “two” “three” “four”, or
“twelve” “thirty-four”

234567		“two” “three” “four” “five” “six” “seven”, or
“twenty-three” “forty-five” “sixty-seven”, or
“two” “thirty-four” “five” “sixty-seven”
12.01	“twelve” “point” ”zero” “one”
0.4	“zero” “point” “four”
-5			“minus” “five”, or
			“negative” “five”, or 
			“minus” “sign” “five”

We make an attempt to insert a comma if the word “thousand” is used for the numbers ranging from 1,000 to 999,999.  For example:

For the number		Say
1,234			“one” “thousand-two” “hundred-thirty-four”
“one” “thousand-two” “hundred-and-thirty-four”
“one” “thousand-two” “thirty-four”

But you cannot say the word “comma” as in “one” “comma” “two” “three” “four”.

Rules for Pronouncing Dates
1.	Say the words “slash” and “comma” where needed.
2.	In spelled out dates (see the last example), do not use the ordinal form for the day, e.g. say “five” and not “fifth” or “the-fifth”.

Examples

For the date		Say
11/25/99		“eleven” “slash” “twenty-five” “slash” “ninety-nine”

11/99			“eleven” “slash” “ninety-nine”

December 25, 1999	“December” “twenty-five” “comma” “nineteen-ninety-nine”

3.	For “Year 2000” date pronunciations please see the following examples:

Examples

For the date		Say
11/25/00                     "eleven" "slash" "twenty-five" "slash" "zero-zero"

11/25/2000                 "eleven" "slash" "twenty-five" "slash" "two-thousand"    
(will not work with pathology language)

December 25, 2000   “December” “twenty-five” “comma” “two-thousand”

Rules for Pronouncing Times
1.	Say “o’clock” to see it spelled out.
2.	For :00 say “on-the-dot”.
3.	For other times, dictate either “A-M” or “P-M” which forces the colon.

Examples

For the time		Say
3 o’clock		“three” “o’clock”
3:00			“three” “on-the-dot”
3:22 a.m.		“three” “twenty-two” “A-M”

Moving enrollment files from one user to another  
WARNING!  In an end-user environment only the system administrator should execute this procedure.
•	In this case, the first user will be called Old.  The second user will be called New.  Make sure the second user, New, has been created.
•	With File Manager or Explorer go to the \VVEntSDK\users\New directory and delete all the files except for new.uid.
•	Go to the \VVEntSDK\users\Old directory and copy all of the files to the New directory:
•	Rename the old1.* files to new1.* because these filenames contain up to the first 3 characters of the user name.
If you are copying enrollment files for the same user, but to another machine, create the user first.  Copy the files to the respective directory.  As long as the user logon names are exactly the same on both machines, you can skip the renaming file step.
ViaVoice User Wizard 
The ViaVoice User Wizard program guides the user through audio setup and creating a voice model (enrollment) and saves that information in your personal speech files. The User Wizard program is located in the \VVEntSDK\Bin directory. 
(NOTE: User Names and Voice Models (Enrollment Ids) should not be added using the User  Wizard. Contact your system administrator to add a new user or voice model.) 

Select the User Name and click Next to start the Audio Setup Wizard. 

Audio Setup Wizard
The Audio Setup Wizard presents several windows to help you setup up your microphone. 
1.	The wizard will prompt you to identify the type of microphone and components you have.
2.	With the microphone on, complete all audio tests that the Audio Setup Wizard presents to you.
At this window, for example, click Start and then read aloud the text inside the box. Speak the text clearly in your normal tone of voice, pausing naturally between phrases or after punctuation marks. (Imagine you are speaking to someone for whom English is not the native language). After you have read the sentences, ViaVoice will display the quality of your audio. Should ViaVoice find that the audio quality is poor, click Fixing Poor Audio Quality to learn how to take corrective action.  

During these tests, the Audio Setup Wizard might display information windows. Use the information proposed by the wizard to solve any difficulty you might encounter during audio setup. ViaVoice needs these tests to be completed successfully to setup your system properly. 
Creating a voice model
The creating a voice model process “trains” the system to respond to your voice and speech patterns with greater accuracy
You must give ViaVoice a sample of your voice so that it can understand you. The User Wizard makes it easy for you to do this.
When you see this window, click Start, then read aloud the text in the box, speaking in a normal style. As ViaVoice recognizes you, the text you have read should become gray. In the window below, the grayed words indicate the words that have been recognized. If ViaVoice does not recognize what you say, simply say the text again until it is grayed.      

When you have finished reading this text aloud, ViaVoice displays the Choosing a Story window. Select the story that you want to read aloud for creating your voice model. Read the story aloud using your normal speaking voice.

When ViaVoice has enough recorded data, you will see the Story Finished window. Click Analyze to have ViaVoice create your voice model. However, if you have a strong regional accent, we recommend that you click Continue Reading so that you can record more sentences, giving ViaVoice more data for analysis. Doing everything you can to give ViaVoice as much information about your voice as possible is one of the best ways to ensure excellent recognition accuracy.

You will see this window after clicking Analyze.

Wait until ViaVoice has fully processed your recording before turning off your computer or working with other process-intensive programs. 

Creating Additional Voice Models (Enrollments)
You should create an additional enrollment when:
•	You change microphones or soundcards.  Changing to a different microphone or soundcard may reduce transcription accuracy.  The signal and noise data may not match the information provided by the original microphone during your initial enrollment.
•	You are working in more than one environment. If your original enrollment was completed in a quiet office, you may find that dictating in a noisier environment will result in more transcription errors. Again, as with the original enrollment, each additional enrollment should be performed in an environment similar to that in which you will be dictating. 

Please see your system administrator if you would like to create an additional enrollment. (Note to system administrators: The SmOtest sample provides the ability to create additional enrollment Ids.  

Once the additional enrollment ID (Voice Model) file has been created by the administrator, perform the following:
1.	Start the User Wizard
2.	Select your User Name
3.	Select the new Voice Model name 
4.	Click Next to perform Audio Setup and Analyze My Voice.

Appendix A
This section includes sample reports for radiology and pathology.

RADIOLOGY SAMPLE #1:

CT SCAN OF THE ABDOMEN AND PELVIS: 
 
CLINICAL INFORMATION: Bladder carcinoma.  
 
TECHNIQUE: Contiguous axial CT sections were obtained through the pelvis prior to the administration of intravenous contrast and after the administration of oral contrast.  After the administration of ionic intravenous contrast, 10 mm contiguous axial CT sections were obtained from the lung bases through the symphysis pubis.  
 
FINDINGS: There is a 1.5 cm low attenuation lesion in the inferior portion of the right hepatic lobe that density readings measuring 16.3 Hounsfield units.  Although this may represent a cyst, neither of the CT scan of the lumbar spine dated 6/21/91 (which did evaluate the intra-abdominal organs) nor the ultrasound of 7/19/91 documented presence of a simple cyst.   Please make reference to those reports.  As the prior films are not available for correlation (the patient has signed them out from the department), further evaluation with ultrasound would be of value to determine if this is a simple cyst.  In addition, a few subcentimeter hypodensities are also noted, too small to characterize.  There is also mild prominence of the intrahepatic biliary ducts as well as the common bile duct and the pancreatic duct.  The common bile duct measures 1 cm in greatest dimension.  As per the report of 7/19/91 ultrasound of the report of the 6/25/91 CT, this does not represent a new finding.  There is no evidence for a focal pancreatic mass.  The direct correlation with prior studies is recommended.  
 
Two subcentimeter low attenuation lesions in are noted peripherally in the spleen, too small to characterize.  The spleen is otherwise unremarkable.  A 1.2 cm low attenuation lesion is noted of the posterior aspect of the right adrenal gland, and again correlation with prior films is recommended.  This may represent a low attenuation adrenal lesions or an exophytic lesion of the superior aspect of the upper pole of the right kidney.  In the absence of old films to document stability these should be further evaluated with ultrasound to determine the origin of the lesion and to characterize this is cystic or solid.  The left adrenal gland is prominent, with no mass.  
 
Bilateral symmetrical nephrograms are present, without evidence of  hydronephrosis.  A subcentimeter low attenuation lesion is noted in the inferior pole of the right kidney, which is too small to characterize.  The kidneys are otherwise unremarkable.  
 
No retroperitoneal lymphadenopathy is a identified.  There is no evidence for abdominal or pelvic ascites.  
 
There is a 1.2 x 1.3 cm nodular lesion along the posterior aspect of the bladder on the left, with a few punctate calcifications.  This nodularity extends laterally along the posterior aspect of the bladder on the left and is consistent with patient's known history of bladder carcinoma.  
 
A sclerotic focus is noted in the left iliac wing, and again would recommend correlation with the prior CT scan of 6/25/91 to further evaluate this area.  If this is a new finding, correlation with bone scan is recommended.  
 
Multiple injection granulomas are noted in the buttocks.  
 
IMPRESSION: 
1. FINDINGS CONSISTENT WITH THE  KNOWN HISTORY OF BLADDER CARCINOMA, AS DESCRIBED ABOVE.  
2.  LOW ATTENUATION LESION IN THE RIGHT LOBE OF THE LIVER, LOW-ATTENUATION LESIONS IN THE SPLEEN, AND A LESION NEAR THE RIGHT ADRENAL GLAND ARE IDENTIFIED.  CORRELATION WITH A PRIOR CT SCAN, WHICH ARE SIGNED OUT BY THE PATIENT, IS RECOMMENDED.  IF THESE ARE NOT AVAILABLE, AN ULTRASOUND SHOULD BE OBTAINED OF THE HEPATIC LESION AND THE RIGHT ADRENAL/RENAL LESION AS DESCRIBED ABOVE.  
3.  MILD PROMINENT INTRAHEPATIC BILIARY DUCTS AS WELL AS COMMON BILE DUCT AND THE PANCREATIC DUCT.  THESE FINDINGS WERE DESCRIBED IN AN ULTRASOUND AND A CT REPORT OF 1991.  DIRECT CORRELATION WITH PRIOR STUDIES IS RECOMMENDED IF THEY CAN BE MADE AVAILABLE.  
4.  SCLEROTIC FOCUS IN THE LEFT ILIAC WING.  CORRELATION WITH PRIOR STUDIES IS RECOMMENDED.  IN THE ABSENCE OF OLD FILMS BONE SCAN WOULD BE OF VALUE FOR FURTHER EVALUATION. 

RADIOLOGY SAMPLE #2:
HIGH RESOLUTION CT SCAN OF THE LUNGS: 
 
CLINICAL HISTORY: Eosinophilic granuloma.  
 
TECHNIQUE: 1.5 mm thick high-resolution axial sections were obtained through the lungs at 10 mm intervals.  No intravenous contrast was administered.  
 
No prior CT's available for comparison.  
 
FINDINGS: There are extensive cystic changes and areas of architectural distortion throughout the lungs, with relative sparing of the extreme bases, consistent with a known history of eosinophilic granuloma.  No gross lung nodules are evident in the portions of the lungs that were imaged.  Limited evaluation of the mediastinum shows mild subcarinal lymphadenopathy.  
 
IMPRESSION: 
EXTENSIVE LUNG DISEASE CONSISTENT WITH HISTORY OF EOSINOPHILIC GRANULOMA.  
MILD SUBCHONDRAL ADENOPATHY. 

PATHOLOGY SAMPLE #1:
FINAL DIAGNOSIS:
GRANULATION TISSUE, (CUFF), BIOPSY:
1.	GRANULATION TISSUE AND FRAGMENTS OF SQUAMOUS MUCOSA WITH ACUTE INFLAMMATION.
2.	THERE IS NO EVIDENCE OF MALIGNANCY.

Gross Description:
Received in formalin, labeled with the patient’s name, unit number, and “Cuff granulation tissue” is a 0.3 x 0.5 x 1.2 cm tan-pink soft aggregate of tissue; submitted entirely in cassette A.

Test(s) Performed:		Path Subspecialty: GYS [NC]	[1]
			SP-GROSS & MICRO, L4 [88305]	[1]
Other Specimens:
1.C96A9509	Accession on 19 MAR 96
SKIN: ABDOMEN

PATHOLOGY SAMPLE #2:
FINAL DIAGNOSIS:
	MENISCUS (MEDIAL):
DEGENERATE FIBROCARTILAGE (MENISCUS) AND HYALINE CARTILAGE.
Gross Description:
Received in formalin, labeled with the patient’s name, unit number, and is a soft to rubbery, tan-brown fragment of tissue, measuring 0.2 x 1.0 x 1.8 cm; submitted entirely in A.

Test(s) Performed:		Path Subspecialty: BST [NC]	[1]
			SP-GROSS & MICRO, L3 [88304]	[1]
Other Specimens:
No other specimens for this patient are in the system.

GENERAL MEDICAL SAMPLE #1:
S:	This is an Urgent Care Visit for this 33-year-old female Indian female who presents today with her husband complaining of headache, fever, and myalgias that have been worse since the weekend.  She also has some chronic low back pain which has exacerbated with this illness.  She has a cough that is productive of clear phlegm.  Originally, she describes her illness as lasting for the past two to three weeks, with initial symptoms of sore throat and sinus congestion.  She thought things were getting better but then developed much worse symptoms over this weekend with fever to 102 degrees, worse headache, and cough.  No nausea, vomiting, dysuria, increased frequency.  Her husband and several people at work have been sick as well.  She has no past medical history and is not on any medications other than NyQuil and Nuprin and no known drug allergies.

O:	Temperature 98.4 degrees. 
General: WD WN female, INAD with audible cough during her examination.
HEENT:  Tympanic membranes are clear without erythema or fluid.
PERRLA:  non-injected sclera.  Nares slightly erythematous but no exudate or edema.  Oropharynx – no exudate or edema.
NECK:  Small tender anterior adenopathy; otherwise supple.
LUNGS:  CTA.
CARDIOVASCULAR:  Regular rate and rhythm without murmur.  
ABDOMEN:  Soft and nontender.  
BACK: No CVA tenderness.

A:	1. Bronchitis.

P:	1.   Zithromax for a five-day course.
2.   Encourage fluids, Saline Nasal Spray, and humidifier for symptoms of  sinus congestion.
3.   Robitussin DM for cough.
4.   Ibuprofen or Nuprin p.r.n. myalgias.
1.	Patient and her husband are to return for follow up physical exams in the next few months.

GENERAL MEDICAL SAMPLE #2:
HISTORY:  The patient is a 31 year old man who is status post a laser excision of a T1, N0, M0 squamous cell carcinoma of the right anterolateral tongue.  He has been with no apparent recurrence, when approximately one month prior to surgery, he noted a right angle of mandible mass.  One week prior to surgery, he sought medical consultation for this.  Fine needle aspirate proved this to be a squamous cell carcinoma.  CT scan showed a large mass in the jugulodigastric region with possible impingement on the right tonsillar fossa.

PROCEDURE:  After the induction of an adequate anesthesia and orotracheal intubation, the patient’s neck was palpated, with the finding of the 4 cm, firm, jugulodigastic mass previously noted.  There were no other neck nodes.  Palpation of the tonsillar area, base of tongue and tongue, floor of mouth revealed no suspicious masses or lesions.

The Dedo laryngoscope was then inserted and the tonsils, base of tongue, vallecula, epiglottis, supraglottic larynx, glottis, post cricoid area and pyriform sinus were inspected, with no finding suggestive of a metachronous primary cancer.

The patient’s head was then turned left side down after completion of the laryngoscopy.  Both were then prepped and draped in the sterile fashion.  A Foley catheter had been previously inserted.  The right neck was then prepped and draped in the usual fashion.

A Schobinger type incision was then outlined.  The skin was injected with 1% Lidocaine and epinephrine, and the incision was carried down through platysma to the level of the great auricular nerve and external jugular vein.  The anteroinferior flap was then carefully raised, using sharp and blunt dissection and the electrocautery.  The external jugular vein was elected with the flap.  It had been previously ligated at its superior portion.  This flap was then elevated out to the midline and down to the clavicle to expose the sternal and clavicular attachments of the sternocleidomastoid muscle.  The posterior flap was then elevated back to the border of the trapezius muscle.  The superior flap was then elevated up to the angle of the mandible.  The anterior facial vein was identified and ligated as it entered the inferior portion of the submaxillary gland.  It was then elevated and the capsular structures mobilized off of the gland to prevent injury to the marginal mandibular nerve.  The submaxillary triangle dissection was then undertaken with careful dissection of the submaxillary gland over its superior portion.  Retraction of the mylohyoid revealed the Wharton’s duct.  This was clamped and ligated.  The lingual nerve could be identified in the depth of the dissection, and the hypoglossal nerve was identified medial to the digastic.  The gland was then dissected downward until it was attached at its medialmost portion, to remain part of the en bloc specimen.

Suspicious nodes were palpable deep to the dissection of the submaxillary gland.  The inferior fascial covering of the sternocleidomastoid was then incised at its anterior border, and the internal jugular vein identified.  The carotid sheath was then incised, and the vein carefully freed from its sheath.  The internal jugular vein was then doubly ligated at each end with 0 silk and 2-0 silk suture ligature placed on the inferior stump of the transected vein.  The dissection was the continued up the sheath, freeing the sheath structures from the carotid artery and from the vagus nerve.  As this was done, the sternocleidomastoid was elevated, and the deep cervical fascia identified.  The overlying fat and lymphatic tissue was then ligated, divided and carried up with the sternocleidomastoid muscle.  The phrenic nerve was identified, and carefully protected during the dissection.  The posterior triangle fatty tissue was then clamped and ligated along the clavicle, with the deep fascia as the medial limit.  This was done out laterally to the border of the sternocleidomastoid.  The spinal accessory nerve was sacrificed.  The specimen was then elevated superiorly and, by sharp and blunt dissection, the carotid artery was exposed along its length up to the bifurcation.