The frequency and correlates of earache were studied prospectively among 335 consecutive episodes of acute otitis media with effusion (AOME) diagnosed in a suburban pediatric practice. Earache was severe in 142 (42%) episodes, mild/moderate in 135 (40%), and absent in 58 (17%). The incidence of apparently painless AOME was higher among children less than 2 years old than among older children (25% v 7%). Redness of the completely bulging tympanic membrane was associated with an increased likelihood of earache. Neither gender nor the extent of involvement (one v both ears) was independently related to earache. Earache is not an invariable component of AOME, especially among infants and young children. Detection of all cases of AOME among young children requires a high index of suspicion, even in the apparent absence of earache.