Background <p>In pediatric populations, rhinogenic intraorbital abscess is frequently encountered, typically resulting from the direct extension of acute sinusitis. However, recurrent rhinogenic intraorbital abscess secondary to an occult medial orbital wall trapdoor fracture is extremely rare and often overlooked due to atypical trauma history and subtle imaging features.</p> Case presentation <p>An 11-year-old male pediatric patient experienced recurrent nasal congestion and rhinorrhea with redness, swelling, and pain of the left eye. He was first diagnosed with acute sinusitis, yet conventional anti-infective treatment failed to provide improvement. Radiological assessment indicated a left intraorbital abscess, and further history disclosed repeated facial injuries caused by basketball strikes. Although the preoperative Computed Tomography(CT) did not clearly show a fracture, the integration of clinical presentation and multidisciplinary evaluation indicated that an occult medial orbital wall trapdoor fracture was highly likely to have resulted in an anatomical vulnerability: on the one hand, it might impair normal sinus drainage; on the other hand, it could create subtle fissures, serving as a conduit for recurrent dissemination of sinus infection into the orbit, eventually leading to abscess development. The pediatric patient was treated with endoscopic total ethmoidectomy, frontal and sphenoid sinusotomy, and concurrent intraorbital abscess drainage, leading to significant symptomatic relief and no recurrence over a six-month follow-up period.</p> Conclusions <p>Occult medial orbital wall trapdoor fractures may underlie recurrent rhinogenic intraorbital abscess in pediatric patients, underscoring the importance of thorough trauma history assessment and high-resolution radiological evaluation. In the presence of ocular warning signs or recurrence, prompt endoscopic sinus surgery with intraorbital abscess drainage is recommended to control the etiology, remove the lesion, and optimize clinical outcomes.</p>